HomeMy WebLinkAbout951993.tiffRESOLUTION
RE: APPROVE 1996 CHILD AND ADULT CARE FOOD PROGRAM RENEWAL AGREEMENT
BETWEEN HUMAN SERVICES AND COLORADO DEPARTMENT OF PUBLIC HEALTH
AND ENVIRONMENT AND AUTHORIZE CHAIRMAN TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with the 1996 Child and Adult Care Food
Program Renewal Agreement between the County of Weld, State of Colorado, by and through the
Board of County Commissioners of Weld County, on behalf of the Weld County Division of Human
Services, and the Colorado Department of Public Health and Environment, commencing October 1,
1995, and ending September 30, 1996, with further terms and conditions being as stated in said
agreement, and
WHEREAS, after review, the Board deems it advisable to approve said agreement, a copy
of which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the 1996 Child and Adult Care Food Program Renewal Agreement between
the County of Weld, State of Colorado, by and through the Board of County Commissioners of
Weld County, on behalf of the Weld County Division of Human Services, and the Colorado
Department of Public Health and Environment be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chairman be, and hereby is, authorized
to sign said agreement.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 25th day of September, A.D., 1995.
• (
5
rt
y Clerk to the Board
Deputy C
APP -• DASTOFORM:
y Attorn
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, CO
Dale K. Hall, Chairman
dual
arbara J. KirkmeSre , Pro) -Teed
Constance L. Harbert
W. H. We ster
951993
Gil' 115; 5HR0066
STATE OF COLORADO
Roy Romer, Governor
Patti Shwayder, Acting Executive Director
Dedicated to protecting and improving the health and environment of the people of Colorado
Main Building Laboratory Building
4300 Cherry Creek Dr. 5. 4270 E. 11th Avenue
Denver, Colorado 80222-1530 Denver, Colorado 80220-3716
Phone (303) 692-2000 (303) 691-4700
August 1995
Dear Child and Adult Care Food Program Authorized Representative:
Colorado Department
of Public Health
and Environment
Enclosed are your renewal materials for the Colorado Department of Public Health and Environment, Child and Adult
Care Food Program (CDPHE-CACFP) Fiscal Year 1996 (October 1, 1995 through September 30, 1996). Please complete
the following forms and enclose other needed information as listed below. Return to our office by Monday, September 18
in the envelope provided. Please call us if you choose not to participate this year by Monday, September 18.
FORM
COMMENTS
ACTION
COMPLETE?
RETURN
GENERAL INFORMATION FOR ALL CENTERS
(All types of centers must complete these forms)
Program Renewal Form
Check all boxes to see that information is
couct,t. Make changes as needed and sign.
/Yes _No
Signed Original
Certificate and Statement of
Authority (yellow)
Have two authorized representatives
sign the form.
_Yes _No
Signed Original
Civil Rights Compliance Review
(green)
Place labels on both copies and sign both
copies.
_Yes No
Two Originals Signed
Infant Menus
Complete only if you claim infants on
the CACFP. Return menus for each
meal and snack claimed for each age
group.
_0-3 months
_3-7 months
_8 months to I year
Two weeks of menus
for each meal or snack
claimed for each age
group
Children's Menus
Return menus for two weeks for each
meal and snack claimed.
_Breakfast
_Lunch
_Supper
_Snack
Two weeks of menus
for each meal or snack
claimed
Audit Questionnaire
Complete form and sign.
_Yes _No
Signed Original
(Please submit
FOR-PROFIT CENTERS
these forms in addition to the general
forms listed above.)
Social Services contract for care of
Title XX children
The number of counties you contract
with is?
_Yes No
_Yes _No
_Yes _No
Copies of all contracts
Copy(ies) of 1995 Contracts:
Are contracts current?
Are all contracts enclosed?
Are all pages enclosed?
Attendance sheet for all children
enrolled in September 1995.
Highlight those children for which you
receive Title XX payment.
_Yes _No
Copy of sheet
-OVER-
®P-95199r
FORM
I COMMENTS
ACTION
I COMPLETE?
I RETURN
SPONSOR
(Please submit
OF CENTERS (if you have more than one center)
these forms in addition to the general forms listed above.)
Sponsor Application (CACFP 302)
Complete only once to reflect activities
of all centers and sign.
/Yes No
Signed Original
Multiple Site Information Form
Review and update information as
needed.
V Yes No
—
Original
`
PRICING CENTERS
(Please submit these forms in addition to the general forms listed above.)
Non -Discrimination Policy
Statement
Complete all pages and sign both copies I
11
_Yes _No I
Two Originals Signed
All application materials must be completed and returned to us by Monday, September 18, 1995 to the address listed
below. You may want to consider returning all items Certified Mail.
Child and Adult Care Food Program
Colorado Department of Public Health & Environment
4300 Cherry Creek Drive South
FCHSD-CAC-A4
Denver, CO 80222-1530
Please call us at (303) 692-2330 if you have any questions.
Sincerely,
Kathryn A. Brunner
Administrator
Child and Adult Care Food Program
KAB/dm
Enclosures
(CDPH&CACFP7/95 - c:\renewal\renewcov.958)
951993
_ Renewal Form
CDPHE-CACFP
October 1, 1995 - September 30, 1996 (Annually)
Dear Center CACFP Representative:
This form reflects the most current information the Colorado Department of Public Health and Environment, Child and Adult
Care Food Program (CDPHE-CACFP) has on file concerning your center and its participation in the CACFP. Please review the
form and verify the accuracy of the information. Make the necessary corrections (in red ink) to anything that is not correct and/or
no longer applicable. Sign and return the form to the CDPHE-CACFP by September 18, 1995. If you have any questions,
please contact Wanda Unterzuber at 303-692-2346.
1. CENTER/SPONSOR INFORMATION
Agreement Number: 65103-05
Federal Tax ID Number: 84-6000813 L
Name and Address: FAMILY EDUC NETWORK OF WELD
COUNTY HEAD START
1551 NO 17TH AVE PO BOX 1805
GREELEY, CO 80632-
2.
1 have reviewed this form and certify that the information it contains is correct.
Print Name: Signature:
3.
MAILING ADDRESS
If you would like your reimbursement check mailed to an address different from the above, your W-9 form must reflect the correct address. Call the CACFP
if you have any questions.
4. Number of Centers: 1715 County: Weld
Authorized Representative: 1.77€4.4_, �(-t..��C✓.[, W G�-'�C� 2. TEA -F. E AMMYr- r(
Center Telephone: (970)353-3800 Alternate Telephone: (970)356-0600 Fax:
t'. -Y - .. r
(970)356-3975
5. Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Months Approved for CACFP Participation: 0 0 0 1( 111 P1 0
6. Child care center currently claims 4 meals per child per da
(Child must be in care for 8 hours or more.) Yes No
7.
Casb-ln-Lieu of Commodities:
8. Number of Shifts: 2
• Bkfst AM Sn Lun PM Sn Sup Late Sn
r��w���„s o `k zr.
Meals Approved: a el
11. Is this a pricing program? Yes N
9. License Capacity: 345
License Number: N/A
License Expiration Date: 9/30/95
Timely Renewal: N
Hours: 6:30A -6:00P
Days Open: MON-SAT
10. Does center care for infants?
Yes No
Does Center claim
frinfst ants on the CACFP?
(up Yes No
12. Center contracts meal service? Yes
13.Cont2dor's Name: 54CHOOL DISTRICTS
(please list additionalicontractors on the back)
14. Food Service Contract Expiration
(please list additional dates on the back)
Date: 6/30/96
15. Meals are: Prepared at the center as 1 Prepared off -site ir 116. Age Range of Participants: 0 to 5
17. FOR PROFIT CENTERS ONLY Eligibility Determination:
According to our records, these are the counties your center has Title XIX or XX contracts with. Please update as necessary.
County Expiration Date: County: Expiration Date:
County: Expiration Date: County: Expiration Date:
18. Request information on advance payments.
Stepa•-Wanda/Debbie--::l Stet, 2 -Specialist
Packet
Receired_ niiElaL Ti e
Card e
Form LtrSent
Packet Irican
follow-up
Initial
Stec l -Specialist:.:,::.
License Capacity or _ Enrollment
FMlow-UPInformation
Card Sent (?) (seeMewl);
c_
alai
send
951993
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951993
APPLICATION FG_.
SPONSOR OF CHILD CARE CENTERS
Agreement Number:
Name
Name and Title of Contact Person:
Tere Keller-Amava
CDPHE-CACFP
65103-05
INSTRUCTIONS: Type or print clearly
I. Name and Mailing Address of sponsor:
Weld County Board of County Commissioners
P.O. Box 758
Greeley, Colorado 80632
relephone Number: ( 970 ) 356 - 40.00
2ounty: Weld
6. Is this a Private Organization? (Private means non -governmental)
Yes No X
Give name and title of Owner of For Profit Title XX center or Chair of the
Organization Governing Boardor Chair of the Church Governing Board:
Dale K. Hall Chairperson
Name Title
.. Do you participate in the Head Start Program?
Yes X No
1. Do you now participate in or have you participated in federally -
funded programs (including CACFP) in the past 3 years?
Yes X No
(If "yes," give name of program(s) and dates of participation.)
Head Start
CACFP
7. Number of CACFP participating centers under your
administration:
Nonprofit Child Care Centers
Outside -school -hours Centers
For Profit Title XX Centers
2 Head Start Centers
Migrant Head Start Centers
Do you participate in the Colorado Preschool Project?
Yes X No
8. Total number of children enrolled at CACFP participating
centers under your administration:
Nonprofit Child Care Centers
Outside -school -hours Centers
For Profit Title XX Centers
12 Head Start Centers
11 Migrant Head Start Centers
. Name and Title of Administrator:
Walter J. Sneckman FxPcutivP Dirertnr
Title
DirPrtnr
Name Title
Telephone Number: ( 970 ) 353 - 1800
9. Do you request advance payments?
Yes No x
10. List any months when you will not claim meals for
reimbursement:
N/A
tescribe your procedure for collecting, maintaining, and reviewing the following records from each center:
I. Income Eligibility Forms (IEFs):
Income Eligibility Forms are completed at the beginning of the school year.
2. Record of Meals Served (ROMS):
Teachers complete Record of Meals Service and turn into Family Services and the infor-
mation is compiled for the Meal Claim Forms.
3. Menus:
At the beginning of the school year menus are formulated with the appropriate School
Districts and approved by Parent Policy Council.
4. Production Records:
Production Records are done by the School District Cooks and reviewed by the Director.
5. Food Receipts and Invoices:
Invoices are approved by the Director and sent to the Fiscal Office for payment and
recording purposes.
CDPHE-CACFP 302 - 7/95 c:\forms)\applspon.ctr)
35198J
DESCRIBE YOUR SYSTEM FOR DISBL ,iNG CACFP REIMBURSEMENT TO YOUR CENTERS WITHIN 5 DAYS OF
RECEIPT FROM THE CDPHE-CACFP. (Reimbursement cannot exceed the CACFP meals claimed for that center by the sponsor.)
All centers are operated under the direction of the Head Start Program. Therefore,
the CCFP Reimbursement is made to the one program and does not need to be disbursed
to the other facilities. All costs for each of the centers are paid under the one
Head Start Budget.
WILL YOU CONTRACT WITH A FOOD SERVICE MANAGEMENT COMPANY FOR MEALS? Yes X No
If yes, please give company name, address, and name of contact person and delivery procedures.
Greeley/Evans School District 6 - Food is prepared at the central location, delivered
Weld School District RE -3J to the individual school cafeteria's and delivered
Weld School District RE -5J to the classroom. Proper storage and food transport
are used.
St. Vrain School Dilstrict RE -1J - Food is prepared at the High School and transported
to the classroom, using proper storage/food transport
containers
DESCRIBE YOUR SCHEDULE FOR TRAINING ADMINISTRATIVE AND FOOD SERVICE PERSONNEL ON THE CACFP
REQUIREMENTS. (Give dates of training session(s) and topics to be covered.)
All staff involved in food service will be trained in October. When new information
is made available, training is provided to all necessary staff, reviews are
conducted monthly when all the documentaion is collected for reoortina purposes.
DESCRIBE YOUR PROCEDURE FOR CONDUCTING PRE -APPROVAL VISITS TO NEW CENTERS. (If available, attach a
copy of your pre -approval evaluation form.)
The pre -approval evaluation form will be used at each site.
PROVIDE A SCHEDULE FOR MONITORING FOOD SERVICE OPERATIONS AT YOUR CENTERS.
Monitoring of food service operations is done in November 1995, February, May,
June, and Aunust of 1996.
If problems are discovered during a monitoring review, what corrective procedure will you follow?
An action plan will be written and follow-up in thirty (30) days.
(CDPHE•CACFP302)
3 Page 2
95199
l- .. & Adult Care Food Program
CIVIL RIGHTS COMPLIANCE REVIEW
The Colorado Department of Public Health and Environment. Child and Adult Care Food Program is required to conduct a preaward civil rights
compliance review of centers or sponsors of centers applying for CACFP participation. Please complete the following information:
t . List the percentages for each racial/ethnic group in the community served byyour center. Usually this information can be obtained from the j
school district Chamber of Commerce. Census Bureau. or Public Library. If you have more than one center, combine this information for all centers.
.05 %
.05 %
American Indian or Alaskan Native
Asian or Pacific Islander
Black (not of Hispanic origin)
79 % Hispanic (a person of Mexican, Puerto Rican, Cuban, Central or
South American, or other Spanish culture or origin, regardless of
race)
21 % White (not of Hispanic origin)
2. *Count the actual number of children enrolled in your center for each group listed below. Write the number in the space provided. If
you have more than one center, combine this information for all centers.
American Indian or Alaskan Native Hispanic (a person of Mexican, Puerto Rican, Cuban. Central or
South American, or other Spanish culture or origin, regardless of
Asian or Pacific Islander race)
Black (not of Hispanic origin) White (not of Hispanic origin)
*Visual identification may be used by centers or sponsors to determine the child's racial/ethnic category. A child may be included in the group to
which he or she appears to belong, identifies with, or is regarded in the community as belonging. Parents/Guardians may be asked to identity the
racial/ethnic group of their own child only after it has been explained, and they as well as we understand that the collection of this information is
strictly for statistical reporting requirements and has no effect on the determination of their eligibility to receive benefits under the Program. As
new children are enrolled, you will need to determine their racial/ethnic background and keep this information in a confidential place.
3. The CDPHE-CACFP annually sends a press release for your center(s) to the local newspaper. Do you do any additional activities to
assure that minority populations and grassroots organizations have an equal opportunity to participate or are informed about changes in the
Program? Yes X No If yes, please check all that apply:
X
X
Distribution of brochures of Program information at public locations
Public service announcements in local newspaper, on radio, or on television (circle media type used)
Paid advertisements in local newspapers
Other. Please explain:
Do or will the items you checked above include the following nondiscrimination statement? Yes X No
In the operation of the Child and Adult Care Food Program, no child will be discriminated against because of race, color, national origin,
sex, age, or handicap. Any person who believes that he or she has been discriminated against in any USDA -related activity should write
immediately to the Secretary of Agriculture, Washington, D.C. 20250.
4. Is membership in a specific organization required before children can be enrolled? Yes No _X —
If yes. please explain
5. Have you ever been found to be in noncompliance of the Civil Rights laws by any federal agency? Yes No
If yes, please explain
We assure the Colorado Department of Public Health and Environment, Child and Adult Care Food Program that all enrolled participants in
the Child and Adult Care Food Program at the center(s) described on the application forms are served the same meals at no separate charge
regardless or race, color, national origin, age, sex, or handicap, and there is no discrimination in the course of the meal service.
Signature of Administrator or Authorized Representative Date
Signature of the CDPHE-CACFP
Administrator
Title Date
(CDPHE-CACFP revised 7/95 - c:\formsl\civilrgt.frm)
:'31993
L -.1 & Adult Care Food Program
CIVIL RIGHTS COMPLIANCE REVIEW
The Colorado Department of Public Health and Environment, Child and Adult Care Food Program is required to conduct a preaward civil rights
compliance review of centers or sponsors of centers applying for CACFP participation. Please complete the following information:
1. List the
school
for each racial/ethnic group in the community served by your center. Usually this information can be obtained from the
ber of Commerce Census Bureau, or Public Library. If you have more than one center, combine this information tor all centers.
. 05% American Indian or Alaskan Native
Asian or Pacific Islander
. 05% Black (not of Hispanic origin)
78 % Hispanic (a person of Mexican, Puerto Rican. Cuban. Central or
South American. or other Spanish culture or origin, regardless of
race)
21 % White (not of Hispanic origin)
2. 'Count the actual number of children enrolled in your center for each group listed below. Write the number in the space provided. If
you have more than one center, combine this information for all centers.
American Indian or Alaskan Native Hispanic (a person of Mexican, Puerto Rican. Cuban, Central or
South American. or other Spanish culture or origin, regardless of
Asian or Pacific Islander race)
Black (not of Hispanic origin) White (not of Hispanic origin)
'Visual identification may be used by centers or sponsors to determine the child's racial/ethnic category. A child may be included in the group to
which he or she appears to belong, identifies with, or is regarded in the community as belonging. Parents/Guardians may be asked to identity the
racial/ethnic group of their own child only after it has been explained, and they as well as we understand that the collection of this information is
strictly for statistical reporting requirements and has no effect on the determination of their eligibility to receive benefits under the Program. As
new children are enrolled, you will need to determine their racial/ethnic background and keep this information in a confidential place.
3. The CDPHE-CACFP annually sends a press release for your center(s) to the local newspaper. Do you do any additional activities to
assure that minority populations and grassroots organizations have an equal opportunity to participate or are informed about changes in the
Program? Yes X No If yes, please check all that apply:
X
X
Distribution of brochures of Program information at public locations
Public service announcements in local newspaper, on radio, or on television (circle media type used)
Paid advertisements in local newspapers
Other. Please explain:
Do or will the items you checked above include the following nondiscrimination statement? Yes X No
In the operation of the Child and Adult Care Food Program, no child will be discriminated against because of race, color, national origin,
sex, age, or handicap. Any person who believes that he or she has been discriminated against in any USDA -related activity should write
immediately to the Secretary of Agriculture, Washington, D.C. 20250.
4. Is membership in a specific organization required before children can be enrolled? Yes No
If yes, please explain
5. Have you ever been found to be in noncompliance of the Civil Rights laws by any federal agency? Yes No
If yes, please explain
We assure the Colorado Department of Public Health and Environment, Child and Adult Care Food Program that all enrolled participants in
the Child and Adult Care Food Program at the center(s) described on the application forms are served the same meals at no separate charge
regardless or race, color, national origin, age, sex, or handicap, and there is no discrimination m the course of the meal service.
Signature of Administrator or Authorized Representative Date
Signature of the CDPHE-CACFP
Administrator
Title Date
(CDPHE-CACFP revised 7/95 -c:\forms)\civilrgt.frm)
351993
'hild & Adult Care Food Program
Certificate and Statement of Authority
This organization is a:
Nonprofit Organization
Church U For Profit Organization ❑
I, (We), the undersigned, state that the child care center(s) listed on Schedule A of the
Agreement (CACFP 300) or the Multiple -Site Summary Sheet is an integral part of, and
therefore under the direct control of, the governing body of the
Weld County Division of Human Services' Family Educational Network of Weld County
(Name of the Organization, Business or Church)
whose address is 1551 North 17th Avenue, P.O. Box 1805, Greeley
(Street or Route)
( 970 ) 353-3800
(Telephone Number)
(City)
80632
(Zip Code)
and that all funds relating to the Child and Adult Care Food Program (CACFP) will be subject to the control
of the duly constituted governing body of the above -named organization, business. or church and that all
funds received for the operation of the CACFP will be used exclusively for the purpose for which they were
received. The individual(s) whose name and signature(s) appears below is authorized to sign the Claim for
Reimbursement.
AUTHORIZED REPRESENTATIVE(S)
Signature
Tere Keller-Amaya
Print Name
Director
Title
Print Name
Site Manager
Title
is the duly designated Authorized Representative(s) for the Center/Sponsor listed above.
Note: It is to your benefit to have two people designated as Authorized Representatives.
The Authorized Representative(s) is fully -empowered to enter into any agreement with the Colorado Department of
Public Health & Environment CACFP and may act for the above -mentioned center or sponsor in preparing and
signing documents and reports pertaining to the management of the CACFP.
When there is a change of Authorized Representative, it shall be the responsibility of the center or sponsor to
request from this office, Colorado Department of Public Health & Environment CACFP, forms to register the
change. The signature of the Authorized Representative on the Claim for Reimbursement must match the signature
on this form or the Claim cannot be processed and your reimbursement will be delayed.
THIS BOX MUST BE SIGNED
I(we) understand that the information on this form is being given in connection with the receipt of
Federal funds and that all of the provisions of the Agreement (CACFP 300) apply.
C r
,>." WEN IyE K. HALL CHAIRMAN
�`- _w Official Title
09/25/95
Signature of Chair of the Board of a irect ry �i' ._T� '`') Print Name
or Pastor, or Executive Director, orOwnq ` t$ ( .,
Date
(CDPHE-CACFP 306 7/95-c:\forms\cert-soa.PN15))
11993
tild & Adult Care Food Program
AUDIT QUESTIONNAIRE
Organizations receiving federal funds are required to be audited. The information requested on this form will
help us satisfy those requirements. It may be helpful to have someone in your accounting or business office, or
someone on your board who is familiar with auditing procedures, prepare this questionnaire.
Center/Sponsoring
Organization: Weld County Division of Human Services Agreement Number: 65103-05
Family Educational Network of weld County
Address: 1551 North 17th Avenue. P.0 Rox 1805
Greelev, Colorado 80632
1. Do you contract* with an accounting firm to conduct an audit of
your center/sponsoring organization?
2. If your center/sponsor is part of another organization, does the
organization have an organization -wide audit?
Yes x No
Yes x No
(The term "organization -wide audit" means an audit of all funds received by an
organization, including federal, state, local, and private funds. The audit must include
a random sampling of all federal funds received by the organization, and it must be
conducted by an independent auditor.
3. Is a review of the CACFP included in that organization -wide audit? Yes x No _
4. What is the legal name of the organization being audited?
Weld County Division of Human Services
5. What federal funds does your organization receive other than CACFP?
(Examples: National School Lunch Program, Title XX)
Head Start Reoion VIII
Migrant Head Start Reoion XII
$
1 6 million
1.4 million
6. What is the total annual budget for the organization identified in Question #4?
(include all federal, state, and "other" funds) $ 6,500,000 00
7. When does your organizations's fiscal year begin and end?
January 1st through Dpremhpr 1st
8. Does your organization have fiscal year end schedules (financial statements)? Yes x No _
9. Does you organization have computerized records? Yes y No _
* ALL audit contracts must include the paragraph on the reverse side of this form.
• Questionnaire prepared by: Date:
Title: Phone Number: ( )
(CDPHE-CACFP 7/95 c:\ Forms\AuditQue.PM5) �(�JJ}�- 7��
TA?
Certification Regarding Debarment. etc,:
This Certification is given by the Contractor in compliance with regulations implementing Executive
Order 12549, Debarment and Suspension, 7CFR Part 3017. Section 3017.510. The Contractor hereby
certifies. by execution of the contract, that neither it nor its principals is presently debarred, suspended,
proposed for debarment, declared ineligible or voluntarily excluded from participation by any federal
department or agency.
951993
"ONSOR STAFFING PATTERN FOR C.„—, P (List all sponsor personnel who will be inv.....::i in administering the CACFP in the
art below. Complete chart as specified, recording duties of personnel listed in ADMINISTRATIVE DUTIES directly re ated to the
CACFP. Administrative duties include managing finances and operation of CACFP. Attach additional sheets if necessary )
Position
A
Specific
CACFP Duties
B
Number of
Personnel in
this Position
C
Number of
Hours per Day
Each
Employee Will
Spend on
CACFP Duties
D
Salary Per
Hour
Including
Fringe Benefits
(Indicatevolun-
teen and unpaid
work with "/")
E
Number of
Days Per Year
Each
Employee Will
Spend on
CACFP Duties
F
Source of
Funds For
Salary (CACFP
or other)
G
Annual
CACFP-
Funded
Salary Only
(DxExF)
Administrator
(or equivalent)
Assistant
Administrator
(or equivalent)
Clerical
(or equivalent)
Cook
Other
(specify)
Annual CACFP Administrative Budget Total CACFP-Funded Labor$ -f)-
(Enter CACFP Portion Only)
CACFP-Funded Labor (enter total from above) $
Office Supplies (including reproduction costs)
Postage
Transportation for Facility Monitoring (include mileage multiplied by 20¢)
Telephone
Office Rental/Mortgage Payment and Maintenance
Utilities for Office Area
Other (specify)
Total CACFP Administrative Budget $ -(1-
Annual CACFP Budget for Food Service Operations at Facilities under Your Administration
(Enter CACFP Portion Only)
Food Purchases $
Food Service Labor (salaries of staff preparing or serving meals)
Food Service Contractor Fee 195.000
Nonfood Supplies (napkins, straws, dishwashing detergent, etc.)
Maintenance for Food Preparation, Storage and Service Areas
Rent/Mortgage Payment for Food Preparation, Storage and Service Areas
Utilities
Other (specify)
Total Food Service Operating Budget $ 1.9.5.S.O-
LIST SOURCES OF CASH INCOME SPECIFICALLY FOR THE FOOD SERVICE OTHER THAN CACFP REIMBURSEMENT.
I certify that the information on this application and any other application materials is tine to the best of my knowledge; that I will accept final administrative and financial
responsibility for total Child and Adult Care Food Program operations at all centers under my sponsorship; and that reimbursement will be claimed only for meals served
to enrolled participants: that the CALF? will be available to all eligible participants without regard to race, color, sex, national origin, age or handicap at the approved food
service facilities and that these facilities have the capability for the meal service planned for the number of participants anticipated to be served or meals are provided by a
food service management company in compliance with CACFP regulations. I understand that this information is being given in connection with the receipt of Federal
funds and that deliberate misrepresentation may subject me to prosecution under applicable State and Federal criminal statutes.
♦Signature of Administrator or Authorized Representative Date
CDPHE-CACFP 302) 951.:1
COLORADO
mEmORAnDUm
Board of County Commissioners September 20, 1995
To Dale K. Hall, Chairman Date
From Walter J. Speckman, Executive Director, Human Services
subject: Child & Adult Care Food Agreement
Colorado Department of Health, Child and Adult Care Food Program
Enclosed for signature is an Agreement between the Colorado
Department of Health, Child and Adult Care Food Program and the
Family Educational Network of Weld County, for reimbursement to
FENWC of meals served to children. This Agreement is an on -going
agreement.
If you have any questions, please telephone Tere Keller-Amaya at 353-3800,
ext. 3342.
Hello