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Arizona Department of Child and Adult Care Food Program EXCEL FILE Education Application and Management Plan for Centers CACFP Fiscal Year 2015 portant: Read the instructions before completing this form. The terms used, such as "sponsoring organization", "affiliated centers," "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 eaoopew display or print properly in all Excel versions and on all computers. If that is the case, please compete the pdf application. IMPORTANT: This file will not work properly with "Works", "OpenOffice", or ANY OTHER software besides Microsoft Excel. unoo Section I. Sponsoring Organization Information 1. A. Provide the following organizational information: Name of Organization Today's Date (mm/dd/yyyy) CTD No. DUNS No. Maricopa County Human Services Head Start 08/21/2014 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) C) (D Cn Contact Person E-Mail Address Telephone No. Fax No. (D (1) Maureen Mason masonm002mail.maricopa.gov 480-464-9669 ext 2,480-655-1154 Cl) 0. Type of Organization: Public Entity > 0 City 151 County 0 Military 0 Other (specify): Private Entity 0 For-Profit Organization RI Nonprofit, Tax -Exempt (Attach a copy of your IRS letter of determination of tax -exempt status.) uaanew 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 His) Center Number of Nonprofit Tax- Number of Nonprofit Tax- Number of Nonprofit Tax- Number of Nonprofit Tax- Number of Nonprofit Tax- uosew Exempt Centers: Exempt Centers: Exempt Centers: Exempt Centers: Exempt Centers: 43 Number of For-Profit Centers: Number of For-Profit Centers: Number of For-Profit Centers: Number of For-Profit Centers: Number of For-Profit Centers: 0 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): Free 859 Title XIX and/or Title XX: Free Free Free Reduced 0 Attach FIR documentation to Paid 0 Total Enrollment: 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 #VALUEI #VALUEI D. Is your center open for weekend care? 0 Saturday 0 Sunday 0 Not open on weekends 2. A. List all publicly fl.trided 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 B. Have you, your organization, or any principals identified with your organization ever been 2B. been disqualified from participation in any publicly funded program(s) for violating that 0 Yes C) No 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). 2C, C. If "Yes," were violations corrected and eligibility restored to participate in the program(s)? If "No," please attach explanation. 0 Yes 0 No N/A 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 0 Yes C) No 0 N/A Local Save: CAUsershasonm0021MMason\CACFP 2014-201514 Management Plan Child Care (Rev 2015).xls (PAGE 2 of 12) BELOW qection I. Sponsoring Organization Information (continued) 4 Has any person in your organization who is engaged in any activity related to the administration of the CACFP ever been convicted of a felony? O Yes ® No If "Yes," provide a detailed explanation: 5, 5. Does your organization now participate or has your organization ever participated in program(s) 0 Yes No other than the CACFP that are funded through the United States Department of Agriculture (USDA) (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, 0 O Yes ® No 0 Section II. Management Plan 1. Program Requirement - Disbursement: If you operate multiple centers you must disburse CACFP reimbursements within IC within five working days of receipt from ADE to centers under your administration. Indicate your system for disbursing payments: I ca ,_. 1. Disbursement options cn CD O N/A (operate single (1) center) 0 N/A (centers are part of the same legal entity and the organization maintains a central bank account) O Checks are hand delivered to centers 0 Checks are mailed to centers 0 Centers pick up checks 0 other (attach an explanation) CD Da 2A, 2. A. Program Requirement -Staffing: Do you have written job descriptions that assign CACFP 0 Yes 0 No IR 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 (attach additional pages as needed): Administrative Qualifications (What you look for when hiring for that position) Staff Function Responsible Position (Example: Director must have bachelors degree, 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, Certified Food Safety Manager Train staff Nutritionist Registered Dietitian, Certified Food Safety Manager Menu planning Nutritionist Registered Dietitian, Certified Food Safety Manager Purchasing N/A Maintain records Nutritionist Registered Dietitian, Certified Food Safety Manager "in Enforce civil rights compliance Nutritionist, Ed Area Supervisor Registered Dietitian, Certified Food Safety Manager Conduct self monitoring Nutritionist, Ed Area Supervisor Registered Dietitian, Certified Food Safety Manager Prepare and submit claims Nutritionist Registered Dietitian, Certified Food Safety Manager Ensure accountability of funds Sr. Grants Accountant Bachelors degree erational Qualifications (What you look for when hiring for that position) Staff Function Responsible Position (Example: Director must have bachelors degree, 10 years of day care experience, CPR certified, (i.e. director, cook, teacher) Certified Food Safety Manager, fingerprint clearance card, etc.) Prepare meals N/A Serve meals Teacher, Teaching Assistant Bachelors degree and/or CDA, CPR certified, Food Handlers Card Sanitation/cleaning Teacher, Teaching Assistant Bachelors degree and/or CDA, CPR certified, Food Handlers Card Monitor participants Teacher, Teaching Assistant Bachelors degree and/or CDA, CPR certified, Food Handlers Card Take meal counts Teacher, Teaching Assistant Bachelors degree and/or CDA, CPR certified, Food Handlers Card Maintain records Site Supervisor Bachelors degree and/or CDA, CPR certified, Food Handler's 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 reTirement: (Centers that exhibit successful meal production may have this requirement waived after a successful review.) 0 The cook will complete Daily Meal Production Records on a daily basis. The center director (or another designated staff person) will review the form to ensure the form is completed correctly. C) Other (Attach a detailed plan as to your organization will conduct CACFP meal production records.) CI If waived, provide date (obtained from past review documentation): Local Save: Calsers\masonm0021MMason1CACFP 2014-2015\4 Management Plan Child Care (Rev 2015).xls (PAGE 3 of 12) BELOW 9ction 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 C) 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: 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 served to program staff and the number of meals served to non-program 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. 0 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 11/1/2014 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): El Single site — not applicable. Proposed Monitoring Dates (Month/Year) Name of Center Free/Reduced % Visit 1 Visit 2 Visit 3 See attached monitoring plan 100% Free Local Save: CAUsershasonm0021MMason\CACFP 2014-201514 Management Plan Child Care (Rev 2015).xis (PAGE 4 of 12) BELOW ,Section II. Management Plan (continued) Program Requirement— Monitoring (continued) B. You must demonstrate that you have an adequate number of staff to conduct required monitoring. r 68, Do you sponsor 25 or more facilities? (3, Yes Os No If 'Yes, submit a monitoring policy addressing 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: El On site: Main business address at: 234 N. Central, Phx AZ B. in addition, all CACFP records must be retained for a period of five years. These records are stored at: 239 N. Central, Phx AZ 8. Program Requirement — Disclosure: Organizations applying to participate In the cAcrp 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 thR allowability of a particular cost. Do you have any expenses that require disclosure? 0 Yes 0 No 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: ID N/A (No CACFP function will be subcontracted.) 2 Food Service El Data Processing El Bookkeeping ri Auditing - Name of auditor: ID Other (Explain): lg. Program Requirement Responsible Principals: All contracting organizations must provide information for at least two ersons 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 Executive Director Bruce Liggett Chairman of the Board Ateela 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: El Organizational Chart (chain of command) is included with this application [required] El Last three months of bank statements are Included with this application [required] El CACFP RENEWAL certificate is Included with this application. If new, provide Business, Nutrition, and Computer certificates [required] E Copy of outside employment policy (see draft attached to instructions) is Included with this application [required] 2 Copy of DHS or other current license for each center [required] NEXT 6 ITEMS MAY BE REQUIRED UNDER THE FOLLOWING CONDITIONS (Indicate checkboxes If Included with this application): El IF your organization subcontracts with another business entity for any aspect of food service, provide a copy to AIDE (see No. 9 above), ID IF -your organization Is a NON- PROFIT, PROVIDE proof of tax exemption for nonprofit organizations. El IF your organization is a NON- PROFIT, list each member of the Board of Directors with address. ID IF you have an "At-Risk After School Snack/Meal Program", PROVIDE facility area eligibility/enrichment activities, El IF you are a Sponsoring Organization with 25 or more facilities, SEND a copy of the policy addressing monitoring FTE's. 1:1 IF you checked 'Yes" to number 8 (above), provide an explanation of any expenses that require disclosure, Local Save: OlIsershasonm0021MMasen1OACFP 2014-201514 Management Plan Child Care (Rev 2015).XIs (PAGE 5 of 12) BELOW Section III. Budget A. Administrative Labor Nonp rof it Food Service Administrative – Labor Justification — This section is used to provide detailed information for each administrative position that has nonprofit food service responsibilities and is paid from the nonprofit food service account. 2. A. Administrative Benefits udoopew 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, Alunoo employment taxes, fringe benefits, overtime pay, holiday pay, compensatory leave, incentive payments and severance pay. (Attach additional pages as needed.) [calculated] [calculated] umunH B. a G. 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 Bowes 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) determination, enrollment, etc.) (If open weekdays + 1 weekend day per week, less holidays (8)= 304 days.) Position: CACFP Duties: (list position to calculate labor cost) X I nainew uoseiN Position: CACFP Duties: (list position to calculate labor cost) X I X Position: CACFP Duties: (list position to calculate labor cost) X I X Position: CACFP Duties: (list position to calculate labor cost) X I X tualsAs :oleo Position: CACFP Duties: (list position to calculate labor cost) 171,0Z19Z16 X I X Position: CACFP Duties: (list position to calculate labor cost) X I X Administrative Cost - Labor: l$0 $0 (1A) (2A) Local Save: CAUsershasonm0021MMason\CACFP 2014-2015\4 Management Plan Child Care (Rev 2015).xls (PAGE 6 of 12) BELOW Section HI. Budget (continued) B. Operational Labor nprofit Food Service Operational – Labor Justification — This section is used to provide detailed information for each operational 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. edoopew Operational labor includes the preparation and service of meals to participants. Labor costs include base salary, Awnoo employment taxes, fringe benefits, overtime pay, holiday pay, compensatory leave, incentive payments and severance pay. (Attach additional pages as needed.) a D. E. F. a uewnH Salary/Wage Gross Hours per day per day Annual CACFP Pay CACFP portion of owes for CACFP Salary/Wage (B x C x D) Number of (E x F) benefits (see duties only per hour [all numbers work days [all numbers instructions Section CACFP Duties (preparing and serving calculated in this calculated in this Ill, Budget — H)* meals, completing point of service, etc.) column] column] Position: CACFP Duties: (list position to calculate labor cost) X I X uewnew Position: uosew CACFP Duties: (list position to calculate labor cost) X I X Position: CACFP Duties: (list position to calculate labor cost) X I X Position: CACFP Duties: (list position to calculate labor cost) X I X waPAS Position: :Neu CACFP Duties: (list position to calculate labor cost) X I X 1.0Z19ZI6 Position: CACFP Duties: (list position to calculate labor cost) X I X Operational Cost - Labor: po $0 : raid Vacation, Military Leave, Sick Leave, Health & Retirements Benefits, Disability, and Life Insurance (1 B) (2B) Local Save: CAUsersImasonm0021MMason\CACFP 201 4-2015 14 Management Plan Child Care (Rev 2015).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 calculated. Include only those expenses paid from the nonprofit food service account. Attach additional panes as needed. J. a Annual Cost For c o Budget Line Item Nonprofit Food Service c a 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. 2 You must explain how you determined your cost figure. a. Food costs were determined by: $ Total dollar amount for invoices from food service vendors, increase number fD Zl- of sites, and percent increase of food cost w M $637,029.00 CD a a S N/A (Check this box only if no cost in this category is paid from the nonprofit food service account.) (field calculated below) ca A Food Costs for: Maricopa County Human Services Head Start: 3B. $637,029 Supplies and Equipment — This category includes nonfood consumables, cleaning products, and CACFP office supplies. E a c You must explain how you determined your cost figure. , a) CD = Kitchen Cleaning Supplies: i i i i $0.00 Paper goods (non-food consumables): NO111I111111I $0.00 El N/A (Check this box only if no cost in this category is paid from the nonprofit food service account.) (field calculated below) nri Supplies and Equipment Costs for: Maricopa County Human Services Head Start: 4B. $0 1 7'1 4C. Commodity Supplemental Food Program (CSFP) The United States Department 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 walsAS :am PLOZ19Z16 Local Save: CAUsershasonm0021MMason\CACFP 2014 -2015\4 Management Plan Child Care (Rev 2015).xls (PAGE 8 of 12) BELOW lotion III. Budget - ADMINISTRATIVE Facility Costs I ror 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% Maricopa 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 County (Admin Sq. Ft.) (Total Sq. Ft.) Administrative (office space) % (percentage rounded up) (calculated) Human Itemized Facility Costs You must explain how you determined your cost figures. Annual Cost For Nonprofit Food Service ADMINISTRATIVE K. L. M. N. Services Itemized Service (calculated fields) (calculated fields) (calculated fields) Is the facility owned, owned and fully depreciated, or lease/rented? Total Annual Percentage of Total Head billed amount expenses (L x M) [o Owned 0 Owned and fully depreciated 0 Lease Space/Rented attributed to CACFP Start 5. Depreciation or Rent: [Should use 12 months for consistency.] [ERROR], COMPLETE ADMIN SQ. FT. ABOVE TO CALCULATE X % (monthly rate) (# months) (calculated) (5A) 6. Contracted Services: Specify each item. uaamemi Contractor (from page 4, question 9) X uosew (contractor/description) (monthly cost) (# months) X (contractor/description) (monthly cost) (# months) % X -tractor/description) (monthly cost) (# months) X (contractor/description) (monthly cost) (# months) (6A) 7. Communications: Specify each item. X (description - phone service) (monthly cost) (# months) X (description - Internet service) (monthly cost) (# months) X (add ADMIN communication) (monthly cost) (# months) X walsAs (add ADMIN communication) (monthly cost) (# months) X :alEa (add ADMIN communication) (monthly cost) (# months) X (add ADMIN communication) (monthly cost) (# months) (7A) 171.0ZI9Z/6 8. Other Costs: Specify each item. 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: CAUsershasonm002\MMason\CACFP 2014-201514 Management Plan Child Care (Rev 2015).xls (PAGE 9 of 12) BELOW ^lotion III. Budget - OPERATIONAL Facility Costs Vor 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% Maricopa Square footage of CACFP (food service) area ÷ Square footage of the total facility = percentage of expenses attributable to CACFP ( Operational (locked because County Operational (Food Service) % (percentage rounded up) Sq. Ft. here) already provided) (calculated) Human Itemized Facility Costs You must explain how you determined your cost figures. Annual Cost For Nonprofit Food Service OPERATIONAL K. L. M. N. Services (calculated fields) (calculated fields) (calculated fields) Itemized Service Total Annual Percentage of Total billed amount expenses (L x M) Head attributed to CACFP 5. Depreciation or Rent: [Should use 12 months for consistency.] [ERROR], COMPLETE ADMIN SQ. FT. ON PAGE 8 Start X Sq. Ft.? Sq. Ft.? I % I (monthly rate) (# months) (calculated) (5B1 6. Contracted Services: Specify each item. uaainew Contractor (from page 4, question 9) X (contractor/description) (monthly cost) (# months) uosew X (contractor/description) (monthly cost) (# months) X , tractor/description) (monthly cost) (# months) X (contractor/description) (monthly cost) (# months) (6B) 7. Utilities: Specify each Item. tri X (description - electriclgas) (monthly cost) (# months) X (description - water) (monthly cost) (# months) X (description - waste) (monthly cost) (# months) X (other utility) (monthly cost) (# months) 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) X (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. IF Sponsors may use up to 15% of the projected annual CACFP reimbursement to pay for actual allowable administrative costs incurred in the 0 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): R. S. Annual Cost For Name of Center - Indicate how you determine administrative and Nonprofit Food Service Nonprofit Food Service operational costs ADMINISTRATIVE OPERATIONAL Total Unaffiliated Center Costs 9A. $0.00 9B. $0.00 Warne Section III. Budget (continued) U0Selig FY2015 BUDGET 10. A. Projected Annual CACFP Administrative Expenses Administrative Costs (rounded) . Administrative Cost - Labor: 1.A. $0.00 711 Administrative Cost - Benefits: 2.A. $0.00 5.A. Administrative Cost - Depreciation or Rent: 5.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. $0.00 Operational Costs (rounded) 1.B. Operating Cost - Labor: 1.B. $0.00 2.B. Operating Cost - Benefits: 2.B. $0.00 3.B. Operating Cost - Food: 3.B. $637,029.00 4.B. Operating Cost - Supplies: 4.B. $0.00 5.B. Operating Cost - Depreciation or Rent: 5.B. $0.00 6.B. Operating Cost - Contracted Services: 6.B. $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. $637,029.00 Local Save: CAUsershasonm0021MMason\CACFP 2014-201514 Management Plan Child Care (Rev 2015).xls (PAGE 11 of 12) BELOW 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 oraanization. z A. Total projected annual nonprofit food service costs A (add 10A + 10B above): z r- c 11.A. $637,029.00 A B. Projected annual CACFP reimbursement for the upcoming fiscal year C c c (based on previous FY reimbursement. New applicants see Reimbursement .c- = Projection Worksheet): 11. B. $260,828.00 z c C. Per the Code of Federal Regulations (CFR) 226.16(b)(1), administrative costs =- A charged to the program should not exceed 15% of projected annual nonprofit food service costs (divide; 10A above + 11A): 11. C. 0.00% a c D. Other non-CACFP income to cover remaining food service costs (tuition, DES a e subsidies, donations, etc.) (subtract; 11A - 11B). This income must be u m specifically designated for use in food service: 11. D. $376,201.00 A E. Total projected funds required for the operation of a non-profit food service C o (add; 11B + 11D which should be the same as 11A): E. , 11. E. $637,029.00 A 3 C a- a 3 cv ci C Notes : un4sAS :elea 171.0ZI9Z16 Local Save: CAUsers\masonm0021MMason1CACFP 2014-2015\4 Management Plan Child Care (Rev 2015).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 Alecia Jackson 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; ea0311eW • The Institution itself, and the Institution's principals, are not currently on the CACFP National Disqualified List; • 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 unoo 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 • 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). • All staff have been trained according to the CACFP training requirements. (.1) Any of the above information that has changed since the initial application has already been submitted to the Arizona Department 1^f Education or is being submitted with this certification. mu) I certify that all of the above information is true and correct. I ueeme /2-1-0/ z\-- 0, Signature - Offid03of Organization ' Date Title uosew Printed Name of Signing Official FOR ADE USE ONLY Effective Date: Signature - ADE Representative Date Title of the ADE Representative END OF APPLICATION P.qinning of fiscal yr: October 1, 2014 End of fiscal yr: September 30, 2015 updated 07/01/2014 es Local Save: CAUsershasonm002\MMason\CACFP 2014-2015\4 Management Plan Child Care (Rev 2015).xls