Claim For Reimbursement - Child And Adult Care Food Program Form (Page 2 of 2) in pdf

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

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.

Claim For Reimbursement - Child And Adult Care Food Program Form Page 2