Dss Form 3359 - Application For Participation Page 7
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9INSTRUCTIONS FOR DSS FORM 3359
All organizations must complete a DSS Form 3359 and DSS Form 3358.
The CACFP Agreement Number is assigned by the South Carolina Department of Social Services (SCDSS). If your organization has
not participated in this program before, this number will be entered by SCDSS. If you are adding a center to your sponsorship, enter
agreement number, which begins with the letters ES and ends with five numbers.
Give the Federal Identification Number assigned to your organization by the IRS. This number should be taken from your tax
documents and should agree with the information listed on the W-9 form, which is part of this application package. If your W-9
indicates that you are a sole proprietor (100% ownership), please include your Social Security number as well as your Federal
Identification Number.
1. Name: The name of your organization. Telephone: The organization’s telephone number. The ESP staff should be able to reach
your organization’s contact person at this number. Fax: The organization’s fax number. If you do not have a fax number, leave this
space blank. Mailing Address: The mailing address of your organization, to include the street or post office box, the city and the
zip. Physical Address: The organization’s physical address, the address where your facility is physically located, to include the
street, city, zip and county.
2. Indicate the date that you would like to be approved to claim meals for reimbursement. Include the month, date and year
(format: mm/dd/yyyy).
3. Check if your organization is classified as a government organization (public), educational institution, for-profit organization,
private nonprofit organization-secular or a Private Nonprofit Organization-Faith Based. If none of these, indicate other and specify
the type of organization.
4. Primary purpose of the shelter.
(Self-explanatory)
5. Residential Child Care Institution: shelters that provide a program of structure care on a long-term basis would be classified as a
residential child care institution (RCCI) and would generally be eligible to participate in the school nutrition programs. However, a
runaway shelter of this type could participate in CACFP only if, in addition to its other activities, it provides temporary housing and
food services to a distinct group of children who are not part of its regular program of care.
6. Age range accepted at the facility.
(Self-explanatory)
7. Check Yes or No to indicate if your organization currently, or has in the past, participated in any programs funded through the
Food and Nutrition Service in the past three years. For example, if you participated in the Emergency Shelter, Afterschool Snack
Program or any other food nutrition programs prior to completing this application, within the past three years, indicate Yes and
then list the name and dates of participation for each of those programs. If you have not participated in any of the food nutrition
programs in the past three years, check No.
8. Check Yes or No to indicate whether or not your organization participates in any other federally funded programs. Federally
funded programs are programs in which you are paid with federal funds. For example, the ABC Voucher Program is funded with
federal funds. If you participate in any other federally funded programs, check Yes and then give the names and dates of
participation for each of those programs. If you do not participate in any federally funded programs, then check No.
9. Check Yes or No to indicate if your organization has ever been terminated from participating in any publicly funded programs. If
your program has been terminated from participating in any publicly funded programs, give the name of the program, dates of
participation and the reason(s) for termination. If not, then check No.
10. Indicate the number of sites that your organization will sponsor for the Emergency Shelter Program. If your organization will be
responsible for more than one site, indicate the number of sites in the space provided. If your organization will only be operating
one site, indicate 1 in the space provided.
11. Indicate if your organization maintains documentation of the full names, dates of birth and periods of all children in residency, by
checking Yes or No. If you check Yes, give the title of the document used to document this information. Who is responsible for
recording information? (Include name(s) and title(s).) Answer this question in a complete sentence. For example: Johnny
Marshall, our area coordinator, is responsible for recording information. Where will the ESP documentation be housed?
Originals and copies?) Answer this question in a complete sentence. For example: All ESP documentation will be housed at the
administrative office and will be kept in a locked file cabinet.
DSS Form 3359 (MAR 15)
PAGE 7
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