Monthly Reimbursement Claim Form printable pdf download

Submit no later than the 15

of the

month following the month covered by

this claim to:

Department of Elder Affairs

Adult Care Food Program

Florida Department of Elder Affairs

4040 Esplanade Way, Bldg B

Food and Nutrition Management

Tallahassee, Florida 32399-7000

Monthly Reimbursement Claim

If this is a revised claim,

(850)414-2048 Fax (850)414-2348

Mark “X” in this box:

Instructions: Return to the above address no later than the 15

of the month following the month covered by this claim. If more than one center is

operated under an approved sponsor, consolidate all data from the centers on one reimbursement claim. Refer to detailed instructions. All monetary

figures must be rounded to the nearest dollar. Do not show cents.

Example: indicate $150.75 as

1. Name and address of sponsor:

Name:______________________________________________________

2. Agreement Number:___________________________

Address:____________________________________________________

3. Report Period: Month____________ Year_________

City:___________________ State:_________ Zip:___________________

4. Number of Operating Days:_____________________

FEID#:______________________________________________________

5. Average Daily Attendance:______________________

Last Name:______________________ First Name:__________________

Phone:_________________________

6. Total Number Centers Operated:___________________

Proprietary Title XIX___________________

All Others___________________________

7. Number of Enrolled Adults by Category: Free___________________ Reduced_____________________ Non needy_____________________

8. Number of Meals Served by Type:

Title XIX

Adult Day Care

Breakfast

A.M. Supplement

Lunch

P.M. Supplement

Supper

9. Program Expenditures and Income:

Operating Expenditures:___________________ Administrative Expenditures:_______________________ Income:_________________________

10. I certify that to the best of my knowledge and belief, this claim is true and correct in all respects, that records are available to support this claim; that it

is in accordance with the terms of existing agreement(s); that payment has not been received; that meals listed on this claim have not and will not be

claimed for reimbursement under Part C of Title III of the Older Americans Act of 1965.

Title:_________________________________________________________________

Signature:_____________________________________________________________ Print Name:__________________________________________

Preparation Date:_______________________________________________________