ATTACHMENT A - MEAL SERVICE APPLICATION REQUIRED DOCUMENTATION LIST
Directions: Provide all of the required documentation for the meal service type for which you are applying, along with the completed
application form. Please keep attachments A and B for your records.
SECTION A: Private For-Profit Restaurant or For-Profit Meal Delivery Service
Required Documentation: (Provide all of the following)
• Copy of a government issued photo identification card and a copy of a Social Security card, or other verification of Social Security
Number, for:
all owners/partners
all officer(s) of private corporations
also provide for spouses of owners/officers if store is located in a community property State (see Part 4 of the application)
NOTE: Above documentation is not required for publicly-owned corporations
• Copy of the contract with the State agency
• Copy of a valid business license
SECTION B: Alcohol and/or Drug Treatment Program
Required Documentation:
• Proof of tax-exempt status as recognized by the Internal Revenue Service
• Certified by the State agency responsible for the rehabilitation of drug addicts or alcoholics (the State Title XIX agency) as:
i. Receiving part B Title XIX funding; or
ii. Operating under part B Title XIX even if no funds are being received; or
iii. Operating to further the purposes of part B of Title XIX, to provide treatment and rehabilitation of drug addicts and/or
alcoholics.
SECTION C: Public or Private NonProfit Meal Delivery Service; Public or Private NonProfit Communal Dining
Facility; Public or Private NonProfit Homeless Meal Provider; Shelter for Battered Women and Children
Required Documentation: For the four meal service types listed above, provide proof of the meal service's tax-exempt status as
recognized by the Internal Revenue Service.
SECTION D: Group Living Arrangement
Required Documentation:
• Proof of tax-exempt status as recognized by the Internal Revenue Service.
• Certification by the appropriate State agency in accordance with regulations issued under 1616(e) of the Social Security Act or
under comparable standards, as determined by the U.S. Department of Agriculture.
SECTION E: Private For-Profit Senior Citizens' Center or Residential Building
Required Documentation:
• If applying as a Residential Building, a signed statement from the owner(s) certifying: (1) that the building is occupied primarily
by elderly persons (60 years of age or older) and SSI recipients and that it prepares and serves meals to such persons, and (2)
that it does not provide a majority of the residents' meals (over 50 percent of three meals daily) as part of the institution's normal
services.
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