Special Milk Reconciliation Form printable pdf download

Special Milk Reconciliation Form

Vendor ID No. _____________

Division of Food Distribution & Warehousing

Claim Month/Yr ____________

Corning Tower Bldg., Room 2925

Empire State Plaza

Albany, NY 12242

SPECIAL MILK RECONCILIATION FORM

This form or its replica must be attached to the Reimbursement Claim Form.

A Purchases –

B. Cost of Milk

D. ½ pints consumed

E. ½ pints consumed by

Convert purchases to

this column

Purchased

½ pints, if necessary.

by ineligible persons

eligible persons

See reverse for

Date of Purchase

must match

conversion chart

receipt

Prior Month

Carryover

(Include Receipts)

TOTAL



Column A must match the attached purchase receipts for the claim month.



Column B is the cost of milk purchased. Carry the total over to Line 9 of the Reimbursement Claim Form.



Column C is the conversion to ½ pints if necessary.



Column D must be completed if purchased milk is consumed by ineligible adults.



Column E is the ½ pts consumed by eligible person. Carry the total over to Line 6 of the Reimbursement Claim

Form.

Records must be maintained for a period of 3 years (See Item 2f of Agreement).

Revised 2013

V:DFDWSpecialMilkFormsMemosInstructionsReimbursement Claim Form2013.doc

Special Milk Reconciliation Form