Extracted text (via pymupdf_layout)
36938 characters
•-• „_ State of Arizona Department of Education Child and Adult Care Food Program 2016 Application Checklist for Renewing CACFP Center Sponsors Copy all documents prior to submitting to ADE @ 1535 W. Jefferson St. Bin #7, Phx, AZ 85007 Centel ADE 111 Application Checldist [Z] El Application and Management Plan (including all required attachments on page 4) El Organizational Chart El Copy of 3 Months Bank Statements I I Copy of Rental Lease (if building is rented) or Depreciation Schedule (if building is owned) ( El Copy of Renewal Training Certificate El Copy of all current CACFP/Civil Rights staff training material/documentation Copy of notification given to centers that unannounced reviews are conducted (multi-site only) 1:1 Copy of current DHS License (or proof that license renewal is being processed) l] Food Service Vendor Contract (if using a caterer/school district for food service) LI Procurement Standards & Guidelines (signed) Civil Rights Pre-Award Compliance Review El Civil Rights Data Collection * Once your hard copy renewal application has been approved, you will be required to update and submit your online application (both site and sponsor) in the CNP Web. Remember, submit the site application(s) first, followed by the sponsor application. Retain the following ADDITIONAL items on site in your CACFP files: Current FY completed income affidavits Production Worksheets Attendance Records-Claiming Rosters & Sign-in/out Sheets Detailed job descriptions for employees with CACFP duties Title XX attendance/billing records* Policies for collection/maintenance of CACFP records Food Service Cost Reports (starting with 1 st claim month) Annual Civil Rights Training Records Monthly Expense Worksheet (starting with 1 st claim month) Procedures for Complaints of Discrimination Time Distribution Reports Administrative Review Procedures Point of Service Meal Count Sheets Computer Generated Meal Count Reports* Meal Count Summary Sheets Monitoring Records, 5-day reconciliations* Daily Meal Production Record for Infants* Training Records for Annual CACFP Staff Training Infant Feeding Preference form* Policies on block claiming & household parental contacts* Menus - CN labels, product analysis, medical statements Permanent Agreement signed by ADE *= If applicable I understand that all CACFP Documentation must be maintained on-site for the current fiscal year and that all CACFP Records must be maintained for five years. By signing below I am acknowledging that I have received the Procedures for Complaints of Discrimination, Purchasing & Procurement Standards, and Administrative Review Procedures. Furthermore, my signature indicates that I have read and understand each of these documents. Date Printed Name of Authorized Signer Authorized Signature Arizona Department of Child and Adult Care Food Program EXCEL FILE Education Application and Management Plan for Centers CACFP Fiscal Year 2016 . -ortant: Read the instructions before completing this form, The terms used, such as "sponsoring organization", "affiliated I ers,pi unaffiliated centers," "principal," "publicly funded," 'National Disqualified List," and 'business related offense," are defined in the "Terms and Definitions" section of the instructions. PLEASE READ: This application was meant to be used in an Excel. Use the pdf application if completing with paper and pen. This file may not display or print properly in all Excel versions and on all computers. If that is the case, please compete the pdf application. IMPORTANT: This tile will not work properly with "Works", "OpenOffice", or ANY OTHER software besides Microsoft ExceL Section L Sponsoring Organization Information 1. A. Provide the following organizational information: Name of Organization Today's Date (trim/cid/my) CTD No, DUNS No, Maricopa County Human Services Head Start 09/21/2015 072631 050391270 Mailing Address (Street or P.O. Box, City, State, ZIP) (Number of months remaining in this CACFP fiscal year,. 2150 S. Country Club Dr. Mesa AZ 85210 Consider basing your budget on 12 months Physical Address (if different) Contact Person E-Mail Address Telephone No. Fax No. Maureen Mason maureen.mason0,asu.edu 4804649669 ex 212 480-655-1154 Type of Organization: Public Entity City El County L] Military Ei Other (specify): Private Entity D [1] For-Profit Organization El Nonprofit, Tax-Exempt (Attach a copy of your IRS letter of determination of tax-exempt status.) U90.111B B. Enter the number of centers and enrollment count for each center under your administration that provides meal service: Child Centers Adult Centers Emergency Shelters At-Risk Centers Head Start (or Outside School Firs) Center Number of Nonprofit Tax- Number of Nonprofit Tax- Number of Nonprofit Tax- Number of Nonprofit Tax- Number of Nonprofit Tax- UOSEV41 Exempt Centers: Exempt Centers: Exempt Centers: Exempt Centers: Exempt Centers: 47 Number of For-Profit Centers: Number of Far-Profit Centers: Number of For-Profit Centers: Number of For-Profit Centers: Number of For-Profit Centers: Number of child participants Number participants that receive Number of participants: Number of participants: Total number participating (all in each eligibility category: Title XIX and/or Title XX benefits: (all in free category): (all in free category): participants are in the free category): Title XiX and/or Title XX: Free Free Free Free Free 836 Reduced Reduced Attach FIR documentation to Paid Paid support site eligibility C. List each of your claimable meal times: Attach additional pages as needed. (format like 11:00 'Insert a space] AM) Meal Type. Breakfast: AM Snack: Lunch: PM Snack: Supper: Evening Snack At-risk Supper At-risk Snack Begin Claim: see End Claim: attached L #VALUEI #VALUEI D. Is your center open for weekend care? Saturday LII Sunday Not open on weekends 2, A. List all publicly funded programs in which you, your organization, and its principals have participated during the past 7 years (attach additional pages as needed): Name of Publicly Funded Program Contact Person Telephone Number Office of Head Start Robert Horne 480-464-9669 B. Have you, your organization, or any principals identified with your organization ever been r 28. been disqualified from participation in any publicly funded program(s) for violating that programs requirements during the past 7 years? Note: If your organization is a "public entity,' limit your response to those individuals who are directly involved in the operations of the CACFP and to their immediate supervisors (responsible principles), C. If 'Yes," were violations corrected and eligibility restored to participate in the program(s)? If "No," please attach explanation. 0 Yes r 2 3. Has any principal in your organization ever been convicted of any criminal business-related offense during the past 7 years? If "Yes", attach a detailed explanation r 3. 0 Yes 10 No 0 N/A Local Save: Msd-s-storage02 mydocs$ masonrn0021MMason CACFP 2015-2016\2016 Application-Mgt Plan (Long Version).xls (PAGE 2 of 12) BELOW Section I. Sponsoring Organization Information (continued) Has any person in your organization who is engaged in any activity related to the administration of the r 4. CACFP ever been convicted of a felony? C.) Yes 0 No If "Yes," provide a detailed explanation: 5. Does your organization now participate or has your organization ever participated in program(s) 5, other than the CACFP that are funded through the United States Department of Agriculture (USDA) O Yes C) No rd. (i.e. National School Lunch Program, Summer Food Service Program)? 0 6, Does your organization operate the CACFP in any other state(s)? If "Yes," please list below: 6. C) Yes C) No lo Section IL Management Plan 1. Program Requirement - Disbursement: If you operate multiple centers you must disburse CACFP reimbursements within within five working days of receipt from ADE to centers under your administration. Indicate your system for disbursing payments: r 1. Disbursement options O N/A (operate single (1) center) ® N/A (centers are part of the same legal entit y and the organization maintains a central bank account) • Checks are hand delivered to centers 0 Checks are mailed to centers 0 Centers pick up checks 0 Other (attach an explanation) S PH 2, A. Program Requirement - Staffing: Do you have written job descriptions that assign CACFP 1-19;S r'A Yes 0 No responsibilities and duties? ..... . ....... . ....... . ........ ..... .......... B. Organizations operating the CACFP must have qualified staff to ensure effective program operation. Complete the chart below to describe the qualifications you require for the person(s) that perform each listed function ID ID (attach additional pages as needed): F, Administrative [Note: One or more of the qualifications that you typed may be cut off, please be sure all text is visable. Qualifications (What you look for when hiring for that position ) Responsible Position Staff Function (Example: Director must have bachelor's de gree, 10 years of day care experience, CPR (i.e director, cook, teacher ) certified, Certified Food Safety Manager, fingerprint clearance card, etc. ) Direct and Manage the CACFP Nutritionist Registered Dietitian, Masters Degree, CPR Certified, Certified Food Safety Manager, fingerprint clearer Train staff Nutritionist Registered Dietitian, Masters Degree, CPR Certified, Certified Food Safet y Manager, fingerprint clearer Menu planning Nutritionist Registered Dietitian, Masters Degree, CPR Certified, Certified Food Safet y Manag er, fingerprint clearar Purchasing N/A Maintain records Nutritionist, Ed Area Supervisor Registered Dietitian, Masters De gree, CPR Certified, Certified Food Safet y Manag er, fingerprint clearer —11 Enforce civil rights compliance Nutritionist, Ed Area Supervisor Registered Dietitian, Masters Degree, CPR Certified, Certified Food Safet y Manager, fingerprint clearer Conduct self monitoring Nutritionist, Ed Area Supervisor Registered Dietitian, Masters Degree, CPR Certi fied, Certified Food Safet y Manager, fingerprint clearar cr) Prepare and submit claims Nutritionist Registered Dietitian, Masters Degree, CPR Certified, Certified Food Safet y Manager, fingerprint clearer Ensure accountability of funds Sr. Grants Accountant Bachelors Degree Operational Qualifications (What you look for when hirin g for that position ) Staff Function Responsible Position (Example: Director must have bachelor's de gree, 10 years of day care experience, CPR certified, C11 (i,e. director, cook, teacher) Certified Food Safety Manager, fingerprint clearance card, etc, ) 43 Prepare meals School Districts Serve meals Site Supervisor, Teacher, Teachir Bachelor's degree and/or CDA, CPR certified, Food Handler's Card, fingerprint clearance card Sanitation/cleanin g Site Supervisor, Teacher, Teachir Bachelor's deg ree and/or CDA, CPR certified, Food Handler's Card, fin gerprint clearance card Monitor participants Site Supervisor, Teacher, Teachir Bachelor's deg ree and/or CDA, CPR certified, Food Handler's Card, fin gerprint clearance card Take meal counts Site Supervisor, Teacher, Teachir Bachelor's deg ree and/or CDA, CPR certified, Food Handler's Card, fingerprint clearance card Maintain records Site Supervisor Bachelor's degree and/or CDA, CPR certified, Food Handler's Card, fingerprint clearance card 3. Program Requirement - Meal Production Records: Organizations must document the menu, a specific listing of foods and quantities used to prepare the meal and the planned number of servings. Indicate the method you will use to meet this requirement: (Centers that exhibit successful meal production may have this requirement waived after a successful review.) r 3. n The cook will complete Daily Meal Production Records on a delis/ basis . The center director (or another designated staff person) "i-'" will review the form to ensure the form Is completed correctly. (1) Other (Attach a detailed plan as to your organization will conduct CACFP meal production records.) '(1) If waived, provide date (obtained from past review documentation): Local Save: 1\hsd-s-storage021m ydocs$1masonm0021MMason \CACFP 2015-2016\2016 Application-Mgt Plan (Long Version).xls (PAGE 3 of 12) BELOW Section •II. Management Plan (continued) Program Requirement — Attendance and Meal Counts: Organizations must maintain records of daily attendance and a daily count of the number of meals served to program participants, program staff, and non-program meals. Meal counts must be taken at the "point of service." The "point of service" is that point in the meal service when you have observed that a creditable meal Was served to an eligible participant. Only the meals served to program participants are eligible for reimbursement. Check the following appropriate items to indicate your method for meeting these requirements: A. Attendance and Count of Meals Served to Participants: 4A. A designated staff person will document on the Point of Service Meal Count Sheets (Centers and Emergency Shelters), when 0 the person observes that a participant has been served a creditable meal. The count will be taken by participant name and by meal type (breakfast, lunch, supper, or snack). The center director (or other designated staff person) will review the form to ensure it is completed correctly. O Other (Specify): B. Count of Meals Served to Program Staff and Non-Program Persons: I— 4B. o No meals are served to Program Staff and Non-Program Persons. A designated staff person supervising the meal service will complete the Point of Service Meal Count Sheets (Centers and Emergency Shelters), to record the number of meals sewed to program staff and the number of meals served to non-program \ 71 persons when the staff person has observed that a meal has been served. The center director will review the form to ensure the form is completed correctly. Meals served to program staff and non-program persons are not reimbursable under the CACFP. O Other (Specify): 5. Program Requirement - Training: A. New staff must receive required CACFP training before they assume responsibility for program functions. Indicate the method you will use to meet this requirement: 5A. I will develop a training package based on the CACFP Business, Nutrition and Computer Track Training and other available program resources. New staff will complete the training before assuming responsibility for program functions. Documentation of the training will be maintained, O Other (Specify): B. All CACFP organizations must provide annual training for all staff involved with operating the Food Program, This training must include topics specific to the CACFP such as meal components, portion size, meal count procedures, eligibility determination, record keeping, and civil rights and the training must be documented with staff sign in sheets, agenda, and any materials provided for use during the training. Please provide a date as to when your organization anticipates holding the training. Complete the chart below to describe the planned training (attach additional pages as needed): Proposed Date (must fall within Required Topics correct fiscal year) Meal Pattern, Meal Count Procedures, Record Keeping, Claims Submission, Civil Rights, and 11/1/2015 Reimbursement System (if applicable) Other Topics (please list)' 6. Program Requirement - Monitoring: Organizations with multiples sites and persons that own multiple independent centers must use the Monitor Evaluation Form to monitor each site or independent center a minimum of three times per fiscal year with no more than six months between visits, A. Complete the following chart to describe your monitoring plans (attach additional pages as needed): LI Single site — not applicable. Name of Center (F) (R) (P) F/R Proposed Monitoring Dates (Month/Year) Percent Visit 'I Visit 2 Visit 3 see attached monitoring plan 100.0%- 4DIV/01 #DIV/OL #DIV/0! #DIV/0! Local Save: asti-s-storage021rnydocs$)masonm01321MMasonCACFP 2015-201612016 Application-Mgt Plan (Long Version).xls (PAGE 4 of 12) BELOW Section II. Management Plan (continued) 6. Program Requirement—Monitoring (continued) B. You must demonstrate that you have an adequate number of staff to conduct required monitoring. r 6Bi Do you sponsor 25 or more fadities? Yes 0 No If "Yes, submit a monitoring policy address/rig number of FTE's assigned with monitoring duties, areas covered and addressing how organizations maintain regulatory monitoring compliance. 7. Program Requirement — Program Document Retention: You must maintain all current fiscal year program documents on site or at the identified main business office, Current fiscal year documents may not be stored in any location that is not accessible to center personnel (i.e. at the residential office of the center owner). The documents must be made available to ADE CACFP reviewers immediately upon request. A. Current fiscal year CACFP documents are located: 0 On site: Main business address at: 2150 S. Country Club Dr. Mesa AZ 85210 B. In addition, all CACFP records must be retained for a period of five years. These records are stored at: 234 N. Central, Phx AZ B. Program Requirement — Disclosure: Organizations applying to participate in the CACFP are required to disclose and identify related-party transactions, less-than-arms-length transactions, and ownership interests in equipment, supplies, vehicles, and facilities, or disclose any other information that inhibits ADE from making an informed assessment of the allowability of a particular cost. Do you have any expenses that require disclosure? If "Yes", attach a detailed explanation. 9. Program Requirement — Subcontracts: Organizations may subcontract certain program functions. If you subcontract, you must keep records to demonstrate compliance with procurement requirements and you must submit a copy of each subcontract. Important Note: You may not subcontract CACFP management functions, such as the preparation of application materials, monitoring, claim preparation, or corrective action processes. Check the functions you plan to subcontract: IA N/A (No CACFP function will be subcontracted.) Ed Food Service E Data Processing LI Bookkeeping E] Auditing - Name of auditor: 0 Other (Explain): 10. Program Requirement — Responsible Principals: All contracting organizations must provide information for at least two persons responsible for the overall operation (attach additional pages as needed). Mailing address cannot be the business. Position Name Non-Business Mailing Address Date of Birth Owner N/A Executive Director Bruce Liggott Chairman of the Board Alecia Jackson Other (specify) Nutritionist Maureen Mason 11. Provide the following documents. Please indicate that you have attached the required information by checking each box below (as applicable): REQUIRED TO BE PROVIDED WITH THIS APPLICATION: Organizational Chat (chain of command) is included with this application [required] Last three months of bank statements are included with this application [required] CACFP RENEWAL certificate Is included with this application. If new, provide Business, Nutrition, and Computer certificates [required] Copy of outside employment policy (see draft attached to instructions) is included with this application [required] Copy of NS or other current license for each center [required] Copy of training materials for current year. This includes; agendas, sign in sheet and presentation materials [required] Copy of written notification provided to centers indicating unannounced reviews will be conducted [sponsors of multiple sites only] NEXT 6 ITEMS MAY BE REQUIRED UNDER THE FOLLOWING CONDITIONS (indicate checkboxes if included with this application): IF your organization subcontracts with another business entity for any aspect of food service, provide a copy to ADE (see No. 9 above). Lii IF your organization is a NON- PROFIT, PROVIDE proof of tax exemption for nonprofit organizations. LI IF your organization is a NON- PROFIT, list each member of the Board of Directors with address. LI IF you have an "At-Risk After School Snack/Meal Program", PROVIDE facility area eligibility/enrichment activities. IF you are a Sponsoring Organization with 25 or more facilities, SEND a copy of the policy addressing monitoring FTE's. IF you checked "Yes" to number 8 (above) , provide an explanation of any expenses that require disclosure. Local Save: 11hsd-s-storage021mydocs$1masonm0021MMason1CACFP 2015-201612016 Application-Mgt Plan (Long Version),xls (PAGE 5 of 12) BELOW Section III. Budget 1. A. Administrative Labor profit Food Service Administrative – Labor Justification — This section is used to provide detailed information for each ..–ninistrative position that has nonprofit food service responsibilities and is paid from the nonprofit food service account. 2, A. Administrative Benefits Maricooa Nonprofit Food Service Administrative – Budget Benefits — See separate instructions, Section Ill, Budget-H. Administrative labor includes planning, organizing and managing the nonprofit food service. Labor costs include base salary, County employment taxes, fringe benefits, overtime pay, holiday pay, compensatory leave, incentive payments and severance pay. (Attach additional pages as needed) [calculated] [calculated] B– G. Human Position (owner, director, monitor, Number of Hours per day Salary/Wage Annual Gross clerk, trainer, etc.) Staff in for CACFP Salary/Wage per day Number of CACFP Pay CACFP portion of Services Position duties only per hour (B x C x D) work days (E x F) benefits (see AND instructions Section CACFP Duties (planning, eligibility (For information only: if open weekdays, less bank holidays (8). 252 days.) III, Budget – H) Head determination, enrollment, etc.) (If open weekdays + 1 weekend day per week, less holidays (8)= 304 days.) Position: Start Nutritionist CACFP Duties: Monitoring, submit monthly claim 1 X 2 X $30.00 = $60.00 X 252 $15,120.00 uaameyd uosein Position: CACFP Duties: (Hst position to calculate labor cost) X I X X Position: CACFP Duties: (list position to calculate labor cost) X I X X Position: CACFP Duties: (list position to calculate labor cost) X I X X wapAs :alea Position: CACFP Duties: (list position to calculate labor cost) st.oztEvoi. X I X X Position: CACFP Duties: (list position to calculate labor cost) X I X X Administrative Cost - Labor: $15,120 ST3 (1A) (2A) Local Save: lthsd-s-storage021mydocs$1masenm0021MMason\CACFP 2015-2016\2016 Application-Mgt Plan (Long Verslon).xls (PAGE 6 of 12) BELOW Section III. Budget (continued) 1. B. Operational Labor ', profit Food Service Operational – Labor Justification — This section is used to provide detailed information for each (ational position that has nonprofit food service responsibilities and is paid from the nonprofit food service account. 2. B. Operational Benefits Nonprofit Food Service Operational – Budget Benefits — See separate instructions, Section III, Budget-H. Operational labor includes the preparation and service of meals to participants. Labor costs include base salary, employment taxes, fringe benefits, overtime pay, holiday pay, compensatory leave, incentive payments and severance pay. (Attach additional pages as needed.) A. B. C—. D. E. Fr Position (Cook and teacher) SalaryNVage Gross Number of Hours per day per day Annual CACFP Pay CACFP portion of AND Staff in for CACFP Salary/Wage (B X C X D) Number of (E x F) benefits (see Position duties only per hour [all numbers work days [at numbers instructions Section CACFP Duties (preparing and serving calculated in this calculated in this Budget — H)* meals, completing point of service, etc.) column] column] Position: CACFP Duties: (list position to calculate labor cost) X I X X L183JrIBIAI UOSBIAI Position: CACFP Duties: (list position to calculate labor cost) X I X X Position: CACFP Duties: (list position to calculate labor cost) X I X X Position: CACFP Duties: (fist postion to calculate labor cost) X I X X walsns Position: a :aie CACFP Duties: (list position to calculate labor cost) 4 WO X I X X ele 40 g Position: CACFP Duties: (list position to calculate labor cost) X 1 X X Operational Cost - Labor: $0 $0 * Paid Vacation, Military Leave, Sick Leave, Health & Retirements Benefits, Disability, and Life Insurance (1B) (28) Local Save: )11-isd-s-sterage021mydocs$1rnasonm0021MMason\CACFP 2015-2O1612016 Application-Mgt Plan (Long Version).xls (PAGE 7 of 12) BELOW Section III. Budget (continued) gram Requirement: The organization must specifically identify each cost item in the budget and, where necessary, explain how each cost was julated. Include only those expenses paid from the nonprofit food service account. (Attach additional pages as needed.) ECIO3pe J. Annual Cost For Budget Line Item Un03 Nonprofit Food Service OPERATIONAL 3, Food — Include only the NET cost of food used (and the net cost of delivered meals), not the cost of all food purchased. uewnH You must explain how you determined your cost figure. Food costs were determined by: sevues Total dollar amount for invoices from food service vendors, increase number of sites, and percent increase of food cost $714,447.00 CD CL in N/A (Check this box only if no cost in this category is paid from the nonprofit food service account.) COI MallicalciCWinci Wol0 Food Costs for: Maricopa County Human Services Head Start: 3B. $714,447 Supplies and Equipment — This category includes nonfood consumables and cleaning products. You must explain how you determined your cost figure. Kitchen Cleaning Supplies: (Note: For consistency, base cost on 12 months.) Paper goods (non-food consumables): (Note: For consistency, base cost on 12 months.) El N/A (Check this box only if no cost in this category Is paid from the nonprofit food service account.) (fieldualculatedbellow) Supplies and Equipment Costs for: Maricopa County Human Services Head Start: 4B. $0 Commodity Supplemental Food Program (CSFP) The United States Deparment of Agriculture (USDA) offers commodity foods to participating CACFP sponsors. The State of Arizona has opted out of this program in exchange for offering cash in lieu. Indicate that you have read the above statement regarding commodities by checking this box UlaiSAS :epa g1.0Z/E1.101. Local Save: \thsd-s-storage02\mydocs$ \rnasonm002\MMason\CACFP 2015-201612016 Application-Mgt Plan (Long Version).xls (PAGE 8 of 12) BELOW Section III. Budget - ADMINISTRATIVE Facility Costs • this worksheet, you will need the following facility square footage calculations: Food Service Area, Office Area, Total Facility Take the determined square footage of the CACFP office space and divide it by the square footage of the total facility . Example: 150 2,500 0.06 or 6% Ba03ple Square footage of CACFP (office space) area + Square footage of the total facility = percentage of expenses attributable to CACFP **required-please complete this sq. ft. equation Ur103 (Admin Sq. Ft.) (Total Sq. Ft.) Administrative (office space) (percentage rounded up) (nlculated) r Itemized Facility Costs You must explain how you determined your cost figures. Annual Cost For Nonprofit Food Service ADMINISTRATIVE cr. CD K. L. M. Z vices Itemized Service (calculated fields) (calculated fields) r Is the facility owned, owned and fully depreciated, or lease/rented? Total Annual Percentage of 7,3 mesa 0 Owned 0 Owned and fully depreciated 0 Lease Space/Rented billed amount expenses --- _I 2 attributed to CACFP bta 6, Depreciation or Rent: [Should use 12 months for consistency.] [ERROR], COMPLETE ADMIN SQ. FT. ABOVE TO CALCULATE % X = E "(monthly rate) (# months) (calculated) (5A) /C) 6. Contracted Services: Specify each item, ID m = Contractor (from page 4, question 9) E X . so up o (contractor/descrIption) (monthly cost) (It months) = X . (contractor/description) (monthly cost) (# months) % x . -tractor/desorption) (monthly cost) (# months) X . (contractor/description) (monthly cost) (# months) (6A) -..T. 7. Communications: Specify each item, n. c. a . x . . , (description - phone service) (monthly cost) (# months) . X . . . (description - Internet service) (monthly cost) (# months) X . ., . ok (add ADMIN communication) (monthly cost) (# months) u X C en . . - (add ADM communication) (monthly cost) (# months) g X e (add ADMIN communication) (monthly cost) (# months) P. . X . . — (add AMIN communication) (monthly cost) (# months) (7A) z, r., 8. Other Costs: Specify each item, c F., . X . (add ADMIN cost) (monthly cost) (# months) . X . . (add ADMIN cost) (monthly cost) (# months) - X . • (add ADMIN cost) (monthly cost) ()/ months) (8A) N/A (Check this box only if no cost in this category Is paid from the nonprofit food service account.) Local Save: 11hsd-s-storago021mydocs$masor m002IMMason \CACFP 2015-201612016 Application-Mgt Plan (Long Version).xis (PAGE 9 of 12) BELOW Section III. Budget - OPERATIONAL Facility Costs this worksheet, you will need the following facility square footage calculations: Food Service Area, Office Area, Total Facility Take the determined square footage of the CACFP food service and divide it by the square footage of the total facility. Example: 525 2,500 0.21 or 21% Square footage of CACFP (food service) area ÷ Square footage of the total facility = percentage of expenses attributable eaoope to CACFP (Operations! (locked because unoo Operational (Food Service) (percentage rounded up) Sq. Ft. here already provided) (calculated) Itemized Facility Costs You must explain how you determined your cost figures. Annual Cost For Nonprofit Food Service OPERATIONAL K. L. M. N. (calculated fields) (calculated fields) (calculated fields) Itemized Service Total Annual Percentage of Total billed amount expenses (Lx M) attributed to CACFP 5. Depreciation or Rent: [Should use 12 months for consistency.] [ERROR], COMPLETE ADMIN SQ. FT, ON PAGE 8 X Sq. Ft.? Sq. Ft.? % (monthly rate) (# months) (calculated) (51) 3 8. Contracted Services: Specify each :tern. usaine Contractor (from page 4, question 9) X (contractorklescrIption) (monthly cost) (# months) uosevti X (contractor/description) (monthly cost) (( months) X iirnntractor/description) (monthly cost) (# months) X (contractor/description) (monthly cost) (# months) (6B) 7. Utilities: Specify each item. X (description - electric/gas) (monthly cost) (# months) X (description - water) (monthly cost) (# months) X 0/0 (description - waste) (monthly cost) (# months) X (other utility) (monthly cost) (# months) 111 X (other utility) (monthly cost) (# months) X (other utility) (monthly cost) (# months) (7B) 8. Other Costs: Specify each item. X (add OPERATIONAL cost) (monthly cost) (# months) X % (add OPERATIONAL cost) (monthly cost) (# months) (add OPERATIONAL cost) (monthly cost) (# months) (PAGE 10 of 12) BELOW 9. Costs for Unaffiliated Centers - Sponsoring Organizations • N/A - All centers are affiliated Sponsors of unaffiliated centers must ensure that each center maintains a nonprofit food service. The information for this section is obtained from the individual budget pages for each center. Sponsors may use up to 15% of the projected annual CACFP reimbursement to pay for actual allowable admin istrative costs incurred in the 0 operation of the nonprofit food service. These amounts are calculated into the budget during the application approval process. Enter the projected CACFP reimbursements and costs for each unaffiliated center. (attach additional pages as needed): 0 IC R. S. Annual Cost For Name of Center - Indicate how you determine administrative and Nonprofit Food Service Nonprofit Food Service operational costs ADMINISTRATIVE OPERATIONAL Sao! Peed 1-1e)S Total Unaffiliated Center Costs 9A. $0.00 9B. $0.00 Section III. Budget (continued) f.n 0 16.1..1I1=1.I FY2016 BUDGET 10. A. Projected Annual CACFP Administrative Expenses Administrative Costs (rounded) Administrative Cost - Labor: 1.A, $15,120.00 -n Administrative Cost - Benefits: 2.A. $0.00 LA. Administrative Cost - Depreciation or Rent: 6.A. $0.00 6.A. Administrative Cost - Contracted Services: 6.A. $0.00 7.A. Administrative Cost - Communications: 7.A. $0.00 8.A. Administrative Cost - Other Costs: 8.A. $0.00 9.A. Administrative Cost - Unaffiliated Costs: 9.A, $0.00 Total CACFP Administrative Expenses: 10.A. $15,120.00 , 10. B. Projected Annual CACFP Operational Expenses Operational Costs (rounded) 'LB. Operating Cost - Labor: i.e. $0.00 2.B. Operating Cost - Benefits: 2.B. $0,00 3.B. Operating Cost - Food: 3.B. $714,447.00 4.B. Operating Cost - Supplies: 4.B. $0.00 5.B. Operating Cost - Depreciation or Rent: 5.e. $0.00 6.B. Operating Cost - Contracted Services: 6.e. $0.00 7.B. Operating Cost - Utilities: 7.B. $0.00 8.B. Operating Cost - Other Costs: 8.B. $0.00 9.B. Operating Cost - Unaffiliated Costs: 9.B. $0,00 Total CACFP Operational Expenses: 10.B. $714,447.00 Local Savo: 11hsd-s-storage021mydocs$1masonm0021MMascn\CACEP 2015-2016\2016 Application-Mgt Plan (Long Version).xls (PAGE 11 of 12) BELOW 1 ' 4 Projected Annual Non-CACFP Income Required for Nonprofit Food Service Costs . Program Requirement: Reimbursements under the CACFP subsidize the nonprofit food service operation but may not be sufficient to cover all food service expenses. Any funds specifically designated as food service account funds are restricted and may not be used to fund any other costs in your organization. A. Total projected annual nonprofit food service costs (add 10A + 10B above): 11. A. $729,567.00 ricooa B. Projected annual CACFP reimbursement for the upcoming fiscal year (based on previous FY reimbursement. New applicants see Reimbursement County Projection Worksheet): 11.B. $324,000.00 C. Per the Code of Federal Regulations (CFR) 226.16(b)(1), administrative costs Huma charged to the program should not exceed 16% of projected annual nonprofit food n service costs (divide; 10A above + 11A): 11. c. 2.07% D. Other non-CACFP income to cover remaining food service costs (tuition, DES Services subsidies, donations, etc.) (subtract; 11A - 11B). This income must be specifically designated for use in food service: 11, D. $405,567.00 Head E. Total projected funds required for the operation of a non-profit food service (add; 11B + 11D which should be the same as 11A): Start 11.E. $729,567.00 Maureen Mason Notes : wets :Kea St.OZ/£1.101, Local Save1\hsd-s-storage021rnydocs$Imasonm0021MMason1CACFP2015-2016\2016Application-Mgt Plan (Long Version),xls (PAGE 12 of 12) BELOW Section IV. Certification This is to certify that Maricopa County Human Services Head Start meets all of the requirements for Renewing (Print Sponsoring Institution Name) Institutions contained in 7 CFR 226.6(b)(2). This means Chrisanda DeBois certifies that: (Print Name of Signing Official) • The management plan on file with the Arizona Department of Education is complete and up to date, Any necessary updates are attached; • No sponsored facility or principal of a sponsored facility is currently on the CACFP National Disqualified List; • The outside employment policy most recently submitted to the Arizona Department of Education remains current and in effect; • The names, mailing addresses, and dates of birth of all current institution principals have been submitted to the Arizona Department of Education; • The Institution itself, and the Institution's principals, are not currently on the CACFP National Disqualified List; ecioapevi • The list of any publicly funded programs institution and principals have participated in the past seven years is current; • The Institution itself, and the Institution's principals, have not been determined ineligible for any other publicly funded programs Awnoa due to violation of the Program's requirements in the past seven years; • No principals of the Institution have been convicted of any activity that occurred during the past seven years and that indicated a lack of business integrity; and umunH • The Institution is currently compliant with the required performance standards of financial viability and management, administrative capability, and program accountability as described in 7 §CFR 226.6(b)(2)(vii). was • All staff have been trained according to the CACFP training requirements. Any of the above information that has changed since the initial application has already been submitted to the Arizona Department of Education or is being submitted with this certification. i -.ertify that all of the above information is true and correct. ueemavg [ D 0115 4c A '31--eur--1- Nturs_e uosevi Signature - Official of Organization Date Title Ck‘r C 5 an_Gt_Ci.- O15 Printed Name of Signing Official FOR ADE USE ONLY Effective Date: Signature - ADE Representative Date Title of the ADE Representative END OF APPLICATION 'ining of fiscal yr: October 1,2015 End of fiscal yr: September 30, 2016 updated 0710112014 as Local Save: F:\3. FY16 Renewal Application Materials\Centers12016 Application-Mgt Plan (Long Version).xls