Dss Form 3359 - Application For Participation Page 2
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912. How will you record the number of meals served to the children each day?
Where will the records be maintained?
n
n
n
n
n
n
Who will be responsible for recording the meal count?
Paid Staff
Volunteer
Parent/Guardian
n
n
Other:
(Specify)
What are you using to record the meal count?
(Attach a copy of the document)
13. Estimated Annual Budget for Food Service Operations at site(s). Sponsors must also complete the budget
summary.
$
Food Purchases
Food Service Labor
$
(Salaries of staff preparing or serving meals)
$
Nonfood Supplies
(Items needed to support meal service: napkins, straws, dish washing detergent, eating utensils, etc.)
$
Total Food Service Operating Budget
14. List personnel who will be involved in administering the Emergency Shelters Program.
(Administrative duties are associated
with planning, organizing and supervising the meal program)
ESP Administrative Duties
Name and Title of Person Who Will Perform Duty
Preparation and Submission of the Monthly Claim for
Reimbursement
Annual Staff Training in the ESP Duties, Responsibilities
and Regulations, If Applicable
Monitoring of Sites to Meet Sponsor’s Self-Review
Requirement, If Applicable
n
n
n
n
15. Is a separate fee charged for meals served to children residing at the shelter(s)?
Yes
No
16. A. List any sources of income specifically for the purpose of food service operations, other than the ESP.
n
n
n
n
B. Would you prefer to receive
USDA-Donated Food or
Cash Payments?
Note: Approved providers who prefer cash payments instead of donated foods will receive such payments. However,
those who choose donated foods may be required to accept cash instead.
17. Responsible Individuals of the Organization: Responsible individuals are individuals who have oversight of the
program.
Name
Title
Date of Birth
DSS Form 3359 (MAR 15)
PAGE 2
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