Advance Payment Request Form - North Carolina Department Of Health And Human Services
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1North Carolina Department of Health and Human Services
Division of Public Health
Women’s & Children’s Health Section
Nutrition Services Branch
Special Nutrition Programs
CHILD AND ADULT CARE FOOD PROGRAM
ANNUAL APPLICATION
ADVANCE PAYMENT REQUEST
(Optional)
Institution Name:
Agreement #:_____________________
Mailing Address:
_______________________________________
Street Address:
_______________________________________
City, State and Zip:
_______________________________________
Advance payments are administered based on considerations of prior reimbursement claims and/or other information as
deemed appropriate with substantiating documentation. By accepting this advance, the Institution agrees that the advance
will be recouped in full through claim deductions beginning with the month for which the advance was received. Advance
payments will not be made after April 2013. If the Institution’s Agreement is terminated and the advance has not been
recouped in full as of the date of termination, the Institution agrees that the outstanding advance balance is immediately due
and payable to the State Agency.
This advance payment agreement will be effective with respect to meals served during the period commencing the
st
th
1
day of
, 20
, and ending the 30
day of September, 2013.
State Agency Representative
Signature on Behalf of Institution
The undersigned represents the Institution and has the authority to request an
advance for and on behalf of said Institution. The undersigned further
represents that s/he has read, understands, and agrees to the terms of this
By: _________________________________
Signature of SNP Unit Manager
request.
By:_____________________________________________
(Must be signed by the same person who signs the Agreement)
Date:_________________________
_________________________________
Title
Date:_________________________
For State Agency Use Only
Approved for Payment
Initials:
Date: _________
DHHS T-CAC 2A (06/12)
Nutrition Services
Submit all four copies to the State Office
Routing: Original – SNP Program File; Yellow: SNP Consultant; Pink: Controller's Office; Gold: Institution
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