Child And Adult Care Food Program Form - North Carolina Department Of Health And Human Services
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2North Carolina Department of Health and Human Services
Division of Public Health
Women’s & Children’s Health Section
Nutrition Services Branch
Special Nutrition Programs
Child and Adult Care Food Program
Institution Name:
Agreement #:_________________
CHILD AND ADULT CARE FOOD PROGRAM APPLICATION PROCESS CHECKLIST
Sponsoring Organizations of Day Care Homes and Centers (Unaffiliated and Affiliated)
Please Check () each item after completion in the first column. Failure to accurately complete all required documents, and submit the required
number of documents requested may delay program approval.
Form (Form No.)
SNP
Special Nutrition
Institution
Regional Consultant
Programs
(use only)
(use only)
(use only)
CACFP Checklist
_______
_______
_______
Advance Payment Request
(optional)
_______
_______
_______
Institution Application
_______
_______
_______
Administrative Budget (DHHS CAC 8A-Homes)
_______
_______
_______
Administrative Budget (DHHS CAC 8A-Centers)
_______
_______
_______
Media Release for SO’s of Centers, if approved
After October 31
_______
_______
_______
Media Release for … SO’s of Day Care Homes
If approved after October 31
_______
_______
_______
IRS Letter of Tax Exempt Status
(private nonprofits), if not submitted in prior year
_______
_______
_______
Participant Information for New Centers
_______
_______
_______
Annual Information Certification for Institutions
_______
_______
_______
For Sponsoring Organizations of Updating Centers
Center Application (CAC 7)(one for each center)
_______
_______
_______
Current federal, state or local license
(One for each facility/center) # submitted_______
_______
_______
_______
Tax exempt letter for private non profit centers
_______
_______
_______
Sponsored Centers Budget (CAC 9A) (unaffiliated centers) _______
_______
_______
Annual Information Certification for facility
(unaffiliated center)
_______
_______
_______
For Sponsoring Organizations of New Centers
Pre-operational visit
or sanitation report(if Applicable) # submitted____
_______
_______
_______
Agreement between Sponsoring
Organization and Facility (CAC 8C)
(unaffiliated centers only) # submitted _____
_______
_______
_______
Attachment A-General Terms and Conditions
Sponsored Centers
_______
_______
_______
Attachment B- Certifications
Sponsored Centers
_______
_______
_______
Attachment C- Notice of Certain Reporting
and Audit Requirements, if applicable
Sponsored Centers
_______
_______
_______
Attachment D – State Grant Certification
No Overdue Tax Debts, if applicable
Sponsored Centers
_______
_______
_______
Attachment E –Conflict of Interest Policy
Sponsored Centers
_______
_______
_______
Center Application (CAC 7)(one for each center)
_______
_______
_______
Current federal, state or local license
(One for each facility/center) # submitted_______
_______
_______
_______
Tax exempt letter for private non profit centers
_______
_______
_______
Sponsored Centers Budget (CAC 9A) (unaffiliated centers) _______
_______
_______
Information on Owners and Principals-Facility
_______
_______
_______
Certification of Single Exclusive CACFP Agreement
Facility
_______
_______
_______
For Sponsoring Organization of Updating Day Care Homes)
Current Day Care Home License
________
_______
_______
Day Care Home Provider Application (8B)
________
_______
_______
Annual Information Certification for facility
________
_______
_______
For Sponsoring Organization of New Day Care Homes
Agreement between Sponsoring Organization and
Day Care Home Provider (new providers) (CAC 8D)
_______
_______
_______
Attachment A-General Terms and Conditions
_______
_______
_______
Attachment B- Certifications
_______
_______
_______
Day Care Home Application (CAC 8B)
_______
_______
_______
Current Day Care Home License
_______
_______
_______
Information on Owners and Principals-Facility
_______
_______
_______
Certification of Single Exclusive CACFP Agreement
-Facility
_______
_______
_______
The following forms will need to be included ONLY if you or your sponsored centers will be receiving catered meals
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