REVISED CACFP PERMANENT AGREEMENT AMENDMENT 1 (3).PDF

ARIZONA DEPARTMENT OF EDUCATION 
Child Nutrition Programs 
1535 West Jefferson Street 
Phoenix, Arizona 85007 
 
CHILD AND ADULT CARE FOOD PROGRAM 
PERMANENT AGREEMENT 
Revised May 2011  
              
                CFDA# 10.558 
                                              
                                              A.G. Contract No.  KR02-1170-ALS  
 
ADE FORM 718 (799) 
22 
CERTIFICATION PAGE 
(Applicable to SPONSORS with governing boards only; 
must be completed and signed before signature page.) 
DIRECTIONS: 
(1) County in which the governing board is located. 
(2) Name of governing board member authorized to sign this certification page. 
(3) City in which governing board meeting regarding the Permanent Agreement was held. 
(4) Date of governing board meeting. 
(5) Legal title of the SPONSOR’S governing board; current year. 
(6) Name of designated official who will be signing the Permanent Agreement (same designated official 
as on line 1, page 20, of the Food Service Agreement). 
(7) Signature of governing board member (same name as on line (2) of this certification page). 
 
Please note that a governing board member cannot designate himself or herself as the Designated 
Official. 
CERTIFICATION 
State of Arizona  
) 
County of (1)  ___________________  ) 
I, (2) ________________________________________, the duly appointed or elected and qualified  
 
Name of Governing Board Member 
member of, and acting on behalf of the governing board, so hereby certify that during a regular meeting 
held in (3) _______________________ Arizona, on (4) _________________________, this governing 
board, by motion made, seconded and carried, approved and authorized execution of an agreement 
between the (5) ___________________________________________________ and the Arizona  
Department of Education, a State Agency, for the purpose of participating in Child Nutrition and/or Food 
Distribution Programs. 
(6)___________________________________ has been designated by the governing board to sign this  
 
Name of Designated Official 
Agreement. 
I further certify that this meeting was duly noticed, called and convened and was attended by a majority 
of the members of the governing board and that approval has not since been altered or rescinded. 
(7) ______________________________________ 
 
Signature of Governing Board Member 
 
(Same as (2) above) 
 
C-22-14-027-G-09
Maricopa County
Bill Gates, Chairman Maricopa County Board of Supervisors
Phoenix
January 26, 2022
Maricopa County
Jacqueline Edwards

ARIZONA DEPARTMENT OF EDUCATION 
Child Nutrition Programs 
1535 West Jefferson Street 
Phoenix, Arizona 85007 
 
CHILD AND ADULT CARE FOOD PROGRAM 
PERMANENT AGREEMENT 
Revised May 2011  
              
                CFDA# 10.558 
                                              
                                              A.G. Contract No.  KR02-1170-ALS  
 
ADE FORM 718 (799) 
23 
PERMANENT AGREEMENT 
 
SIGNATURE PAGE 
 
AGREED TO AND SIGNED: 
 
 
1. 
 ____________________________________  
 _____________________________________________ 
 
(Print or Type Name and Title) 
(Signature of Designated Official) 
 
 
[Same as item (6) on Certification Page, if applicable] 
 
 
 
 ____________________________________  
 _____________________________________________ 
 
(Sponsor/School) 
(Date) 
 
 
 
Address  _____________________________________________________________________________ 
 
 
OTHER AUTHORIZED SIGNATURES 
 
 
2. 
 ____________________________________  
 _____________________________________________ 
 
(Print or Type Name and Title) 
(Signature) 
 
 
3. 
 ____________________________________  
 _____________________________________________ 
 
(Print or Type Name and Title) 
(Signature) 
 
 
4. 
 ____________________________________  
 _____________________________________________ 
 
(Print or Type Name and Title) 
(Signature) 
 
 
 
FOR OFFICIAL USE ONLY 
 
STATE BOARD OF EDUCATION 
 
 
 
 ____________________________________________________________________________________ 
      (Superintendent of Public Instruction or Designee) 
(Date) 
 
Jacqueline Edwards, Director Human Services Department
Eve Del Real, Assistant Director EED
Chrisanda DeBois, HSD EED Nurse
Jacqueline Edwards, Director, Human Services Department 
Maricopa County Head Start Program
234 N. Central Avenue 3rd Floor Phoenix AZ 85004