CLAIM INSTRUCTIONS
Claim Instructions:
* Income Eligibility Forms must be given to all participants and kept on file except At Risk and Head Start programs.
* Participants without an Income Eligibility Form are claimed at the Paid rate.
* All participants must be listed on the Monthly Attendance Records as Free Reduced or Paid.
1. Name of your Institution.
2. ID number – example: 12345-A or 12345-B.
3. Claim month and year.
4. Licensed Capacity: Found on Child Care License.
5. Number of Facilities: Total number of sites.
6. Total Monthly Attendance: Use the Meal Participation Record.
7. Average Daily Attendance: Monthly Attendance divided by number of days meals were served.
8. Number of days CACFP meals were served. Use the Meal Participation Record.
9. Free: Total number of Free participants: Use the Monthly Attendance Record for Free participants.
10. Reduced: Total number of Reduced participants: Use the Monthly Attendance Record for Reduced participants.
11. Paid: Total number of Paid participants: Use the Monthly Attendance Record for Paid Participants.
12. Total Enrollment: Add Free, Reduced and Paid participants.
For Profit Centers: If a claim does not meet 25% of enrollment or capacity, please notify State Agency at 444-4347.
13. Total number of breakfast meals: Use the Meal Participation Record.
14. Total number of lunch meals: Use the Meal Participation Record.
15. Total number of Supper meals: Use the Meal Participation Record.
16. Total number of Snack/Supplement meals: Use the Meal Participation Record.
17. Sign and date Claim Certification.
18. Free/Reduced Certification: Worksheet:
1. Add Free and Reduced participants: 5 Free + 3 Reduced = 8 total Free/Reduced Participants
2. Compare Enrollment and Licensed Capacity numbers, use the smaller number.
Enrollment = 30
Capacity = 40
3. Multiply the smaller number by .25 (30 x .25 = 7.5)
The number of Free/Reduced participants must be equal to or greater than this number to meet the 25%
minimum eligibility to submit a claim for this month.
4. Example # 1: Enrollment = 30 x .25 = 7.5
Example #2: Capacity = 40 x .25 = 10
Number of Free and Reduced participants = 8
Number of Free and Reduced participants = 8
8 is greater than 7.5 (25% of enrollment)
8 is less than 10 (25% of capacity)
This claim is payable.
This claim is not payable
19. Signature of authorized personnel.
20. Current date.
21. Title of personnel signing the claim form.
22. Phone number.