Ade 5-Day Reconciliation Form For Multiple Site Sponsors And Multiple Single Center Participants - Arizona Department Of Education

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ADE 5-Day Reconciliation Form
For Multiple Site Sponsors and Multiple Single Center Participants
(Not Applicable for Emergency Shelters)
Site Name: _______________________________________________________
CTD #: _____-_____-_____
Total Number of Participants Enrolled (based on claim): _____________
Licensed Capacity: ___________
Total Number of Participants Claimed (based on meal counts):
1 Day Before
2 Days Before
3 Days Before
4 Days Before
5 Days Before
Meal
Date:
Date:
Date:
Date:
Date:
Breakfast
AM Snack
Lunch
PM Snack
Dinner
Evening Snack
Total Number of Participants in Attendance (based on sign in/out sheets):
1 Day Before
2 Days Before
3 Days Before
4 Days Before
5 Days Before
Meal Service Times
Meal
Date:
Date:
Date:
Date:
Date:
Breakfast
AM Snack
Lunch
PM Snack
Dinner
Evening Snack
Compare the tables above. Are there any discrepancies between the numbers claimed and the numbers in attendance?
 Yes  No If yes, determine whether an over or under claim occurred and provide details. In addition, list corrective
action assigned to resolve issue:

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