CACFP Agreement #__________
CLAIM FOR REIMBURSEMENT
for Sponsors of Day Care Centers
Sponsor Name
Claim Month
Claim Year
Adjusted Claim?
YES_____ NO_____
Center Number
Center Number
Center Number
Center Name
Center Name
Center Name
Attendance Reporting
Attendance Reporting
Attendance Reporting
Total Days of Operation
Total Days of Operation
Total Days of Operation
Total Attendance
Total Attendance
Total Attendance
Income Eligibility Categories for All Participants
Income Eligibility Categories for All Participants
Income Eligibility Categories for All Participants
Free Category
Free Category
Free Category
Reduced Category
Reduced Category
Reduced Category
Paid Category
Paid Category
Paid Category
Total Enrolled
Total Enrolled
Total Enrolled
0
0
0
For Profit Centers Only
For Profit Centers Only
For Profit Centers Only
Number of Children with Tuition Subsidy
Number of Children with Tuition Subsidy
Number of Children with Tuition Subsidy
Meals/Snacks Served
Meals/Snacks Served
Meals/Snacks Served
Breakfast
PM Snack
Breakfast
PM Snack
Breakfast
PM Snack
AM Snack
Supper
AM Snack
Supper
AM Snack
Supper
Lunch
Night Snack
Lunch
Night Snack
Lunch
Night Snack
Second Meals/Snacks Served
Second Meals/Snacks Served
Second Meals/Snacks Served
Breakfast
PM Snack
Breakfast
PM Snack
Breakfast
PM Snack
AM Snack
Supper
AM Snack
Supper
AM Snack
Supper
Lunch
Night Snack
Lunch
Night Snack
Lunch
Night Snack
At-Risk Snacks/Suppers
At-Risk Snacks/Suppers
At-Risk Snacks/Suppers
Total Days of Operation
Total Days of Operation
Total Days of Operation
Total Attendance
Total Attendance
Total Attendance
Snacks
Seconds
Snacks
Seconds
Snacks
Seconds
Suppers
Seconds
Suppers
Seconds
Suppers
Seconds
FOR STATE USE ONLY
CERTIFICATION by AUTHORIZED REPRESENTATIVE (a completed Certificate of
Authority must be on file). I certify, to the best of my knowledge and belief, that this claim
Comments:
is true and correct in all respects; that records are available to support this claim; that it is in
accordance with the terms and conditions of existing agreements; and that payment
therefore has not been received. I recognize that I will be fully responsible for any excess
amount that may result from erroneous or neglectful reporting herein. Also, I am aware that
deliberate misrepresentation or withholding of information may result in prosecution under
applicable state and federal statutes. I agree to contact CACFP if there are any changes in
the approved application and sponsor agreement.
______________________________________________________________________________________________________________
Signature
______________________________________________________________________________________________________________
Title
Date Signed
PROCESSED_____ RETURNED_____ REJECTED_____
This Form Prepared By
_____________________________________________________________________________________
_____________________________________________
Telephone (include Area Code)
____________________________________________________________________________
Date / Initials
DOH-3703 (12/11)
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