Claim For Reimbursement - Child And Adult Care Food Program Form printable pdf download

Claim Form for Reimbursement

CHILD AND ADULT CARE FOOD PROGRAM

PO Box 202925 Helena, MT 59620-2929

Fax: 406 444-2547

Institution: ______________________________________________________________

(1)

Claim Month_____________ 20_____

(2)

(3)

Claims are due on or before the 10th of each month. Claims not received within 60 days of the claim month will not be paid without

USDA approval for a one-time exception. [REF: 7 CFR 226.10(e)]

Refer to Claim Instructions to complete this page.

This claim form is available on the CACFP web at

Retain a copy for your files.

Center Information:

Monthly Attendance:

Total Number of CACFP

Meals Served to Children:

(4) Licensed Capacity

_______

(9) Free

_______

(13) Breakfast ________

(5) Number of Facilities

_______

(10) Reduced

_______

(14) Lunch

________

(6) Total Monthly Attendance _______

(11) Paid

_______

(15) Supper

________

(7) Average Daily Attendance _______

(12) Total Enrolled _______

(16) Snack

________

(8) Total Days Meals Served

_______

Refer to Monthly Attendance

Refer to Meal Participation

Records

Record

(6,8 refer to Meal Participation Record)

17. I certify that to the best of my knowledge and belief, this claim is true and correct, records are available to support it,

it is in accordance with an existing agreement and applicable licensing requirements, and payment has not be received. I

understand that this information is being given in receipt of federal funds and that deliberate misrepresentation of the

information may be subject me to prosecution under applicable state or federal laws.

18. For Profit Institutions Only: Free/Reduced Certification, See Claim Instruction #18

For Profit Institutions Only: Free/Reduced Certification, See Claim Instruction #18

18.

This institution certifies that at least 25% of enrolled children or 25% of licensed capacity, whichever is less, are

classified as Free and Reduced. Completed IEF’s are on file to meet eligibility requirements for this reporting month.

# of F/R Participant _______

Total Enrollment _____

Licensed Capacity _____

%Result_____

. Authorized Signature__________________________________

Date __________________________

20.

. Title _______________________________________________

. Phone _________________________

Claim For Reimbursement - Child And Adult Care Food Program Form

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