Child and Adult Care Food Program Application

Child and Adult Care Food Program Application

Recitals

WHEREAS Applicant Name: represents an organization seeking participation in the Child and Adult Care Food Program (Program); and

WHEREAS Program Administrator: administers the Program and establishes eligibility, reimbursement, and monitoring requirements that the Applicant must meet; and

WHEREAS Applicant desires to participate and certify to comply with Program rules, fiscal requirements, and food service standards as set forth in the certification below.

Applicant Information

Child Care Center    Day Care Home    Adult Day Care    At-Risk Afterschool    Sponsor of centers/homes

Program Details

Program Operating Start Date:   Projected End Date (if seasonal):

Mon   Tue   Wed   Thu   Fri   Sat   Sun

Breakfast   Lunch   Supper   Snack   Meal Supplement

Self-prepared meals   Purchased from vendor   Claimed through sponsor

Scope of Service

Briefly describe the meals and services to be provided under this application, including populations served, age ranges, and any special meal accommodations:

Banking for Reimbursement (Optional)

Certifications and Assurances

By signing below, the Applicant certifies, under penalty of perjury and administrative sanction, that:

1. All information in this application is true and correct to the best of the Applicant’s knowledge.
2. The Applicant will comply with Program meal patterns, recordkeeping, financial management, monitoring, and civil rights requirements, and will maintain necessary documentation for audit and review for the period required by the Program Administrator.
3. The Applicant will not claim reimbursement for meals that are duplicative, ineligible, or for participants not actually served, and will return any funds determined to be improperly claimed.
4. The Applicant will permit authorized representatives to inspect records, facilities, and meal service operations during normal business hours.
5. False statements or misrepresentations may result in disallowance of claims, termination from the Program, civil or criminal penalties, and repayment obligations.

Applicant further acknowledges the nondiscrimination requirement and agrees not to discriminate on the basis of race, color, national origin, sex, age, or disability in the operation of activities under this Program.

Term and Termination

Program Participation Term Start Date:   Anticipated Term End Date:

Either party may terminate participation or this agreement for cause upon written notice to the other party. Applicant agrees to provide notice of program cessation or material change in operations at least days prior to the effective date of termination, unless immediate termination is required by law or Program Administrator policy.

Confidentiality

Applicant agrees to safeguard participant records and financial information in accordance with applicable confidentiality laws and Program Administrator requirements. Records will be disclosed only as required for Program administration, audit, monitoring, or as authorized by law. Applicant will implement reasonable administrative, technical, and physical safeguards to protect confidential information.

Governing Law and Entire Agreement

This application, upon acceptance by the Program Administrator, together with any attachments and applicable Program policies, constitutes the entire agreement between Applicant and the Program Administrator with respect to Program participation. This agreement will be governed by the laws and administrative rules of the state in which the Applicant operates, and by applicable federal Program regulations to the extent they apply.

Applicant Acknowledgment

The Applicant acknowledges that submission of this application is a request for Program participation and certification that the Applicant will comply with all applicable Program requirements, maintain accurate records, and cooperate with monitoring and audit activities. Applicant understands that approval is contingent upon verification of eligibility and Program compliance.

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