Form Hs 1965A – Fill Out and Use This PDF

Section A. Sponsor Information

1.Complete all of the following information:

If Private Non-profit, please attach a copy of your organization’s federal tax exemption letter from the Internal Revenue Service. If Faith- Based, please attach a letter from the Chairman of the Governing Board or Pastor which authorizes this application, and a copy of the state sales tax exemption letter which was issued to your church by the Tennessee Department of Revenue.

5.List all publicly funded programs in which you, your sponsoring organization and its principals have participated during the past seven years (attach additional pages as needed):

Form HS-1965A

Revised January 2011

Page 2

Section B. Financial Viability

1.Each sponsoring organization must have adequate sources of funds to withstand temporary interruptions in program payments and/or fiscal claims against the organization. To address this requirement, please attach a comprehensive financial statement that identifies all expenditures and sources of income to your organization as a whole for your organization’s last fiscal year. You may attach a copy of your organization’s last audit report in lieu of the comprehensive financial statement.

Section C. Budget

Each sponsoring organization must have adequate financial resources to operate the program on a daily basis. To address this requirement, please complete the following budget information. All program costs must be necessary, reasonable and allowable.

3.Operational Labor – Provide detailed information for each operational position to perform CACFP duties and to be funded by the CACFP meal reimbursements from the TDHS. Operational labor includes the preparation and serving of meals. Labor costs include base salary, employment taxes, fringe benefits, overtime pay, holiday pay, compensatory leave, incentive payments and severance pay.

Position:

CACFP Duties:

Position:

CACFP Duties:

Position:

CACFP Duties:

NOTES: Financial Instruction 796-3, Rev. 3 requires that certain costs receive “Specific Prior Written Approval” by the TDHS. These costs include, but are not limited to, any direct costs that must be allocated between administrative and operating costs, between allowable and unallowable costs, and between the TN CACFP and CACFP costs incurred in other states for multi-state institutions; costs required to make goods or services donated to the institution usable for the program; equipment purchase and depreciation methods; employer costs for in-house publications, first-aid clinics, and employee counseling services; special lease arrangements; allocation of maintenance and operation costs for leased facilities when such costs are included in rent or other special charges; insurances not required by the TDHS; less-than-arms-length financial arrangements or transactions; changes in the institution’s compensation policy that would result in substantial increases in employee compensation; overtime pay, holiday pay for work performed on a non-holiday, and compensatory leave; severance pay; deferred compensation; travel costs and registration fees for attending conferences when the CACFP is only part of a larger agenda; and costs of memberships for civic and community organizations. When such costs are included in your budget, you must

request approval for these costs in a separate letter to the TDHS.

A Written Compensation Policy must be maintained for each position. This policy must address the rates of pay; work hours, including breaks and meal periods; and payment schedules. In addition, a Time and Attendance Report must be completed and signed by each CACFP funded employee for each pay period and also signed by the employee’s supervisor. The Time and Attendance Report must reflect the starting time, ending time, and absences for each working day in each pay period. If any employee will perform both operational and administrative duties under the CACFP, or duties for the CACFP and other programs, a Time Distribution Report must be completed by the employee for each pay period and signed by the employee’s supervisor. The signatures of the employee and employee’s supervisor for the Time and Attendance Report and Time Distribution Report will follow a statement that the information provided by the employee is true and correct. In addition, all payroll records required by Financial Instruction 796-2, Revision 3 must be maintained to support all labor costs charged to the CACFP.

22.Summary of Projected Costs and Revenue

Reimbursements under the CACFP subsidize the non-profit food service operation but may not be sufficient to cover all non-profit food service expenses. Any funds specifically designated as non-profit food service account funds are restricted and may not be used to fund any other costs in your organization.

a.Total annual costs of food service (Section C. 3. – 21.):

b.Enter the projected annual CACFP meal reimbursements from Section C. 2. above:

c.Enter the total of other income to the food service account:

(Other income refers to funds specifically designated for use in food service.)

d.Enter the total of lines b and c:

23.Sponsoring organizations applying to participate in the CACFP are required to disclose and identify related party transactions, less- than-arms-length transactions, ownership interests in equipment, supplies, vehicles, and facilities, or disclose any other information that inhibits the TDHS from making an informed assessment of the allowability of a particular cost.

Form HS-1965A

Revised January 2011

Page 6

Section D. Administrative Capability

Each sponsoring organization must have an adequate number and type of staff with appropriate qualifications to administer the CACFP.

1.Complete the chart below to describe the qualifications you require for any of the following positions(s) that perform CACFP duties. Attach additional sheets if necessary.

CACFP Director/Manager

Teacher

Cook

Monitor

Civil Rights Officer

CACFP Claim Preparer

3.The following information must be provided for the persons responsible for the overall operation of the CACFP. (Use additional sheets if necessary.)

Executive Director

Chairman of the Board

Owner (Proprietary)

Section E. Program Accountability

The sponsoring organization must have internal controls and other management systems to ensure fiscal accountability and program compliance with federal and state regulations.

1.Complete and attach the Sample Form to Document Required Management Controls

2.Enter your organization’s anticipated date(s) for in-house training for the program year beginning October 1 and ending September 30. Training for each employee performing CACFP duties must be provided at least once per program year.

_________________________________________________ ___________________________________________________

_________________________________________________ ___________________________________________________

3.Please identify the names of the personnel to perform the required monitoring reviews of your sponsored centers:

_________________________________________________ ___________________________________________________

_________________________________________________ ___________________________________________________

Each sponsoring organization must ensure that the meals services of each sponsored center is monitored subject to the following requirements: (a) Each center must be visited at least three times each program year to complete the monitoring reviews; (b) The monitoring visits to each center must occur not more than six months apart; (c) One of the required monitoring visits for each center must occur during the first four weeks of CACFP operations; (d) At least two of the monitoring visits to each center must be unannounced; and (e) The findings of all monitoring visits must be identified in written reports which are maintained for inspection by state and federal personnel.

Form HS-1965A

Revised January 2011

Page 8

Section K. Employees to Sign/Electronically Submit Reimbursement Claims (continued)

B.

C.

D.

Section L. Claim Edit Checks

1.Does your organization have the following claim edit checks in place: ___ Yes ___ No

How are they performed: ___ Manually ___ Automated

A.Edit check to ensure that each home is paid only for those meal types for which it has been approved to serve under the CACFP

B.Edit check to ensure that the number of meals claimed by each home does not exceed the number derived by multiplying approved meal types times days of operation times enrollment

Section M. Civil Rights Compliance

All personnel who perform CACFP duties must complete Civil Rights training. To complete this training, please enter the following link on your computer browser: http://tn.gov/humanserv/adfam/ccfp_forms/index.html

At the bottom of the web page, please click on the Civil Rights Training link and then open the PowerPoint training document. When all CACFP personnel have reviewed the training document, please print the Training Roster, enter on the Training Roster the names and job titles of the CACFP personnel who have reviewed the PowerPoint training document, and return the Training Roster with this application.

Section N. Certification

I certify that the information on this form is true and correct to the best of my knowledge, and that I will immediately report to the Tennessee Department of Human Services any changes that occur to the information submitted in my application. I also certify that reimbursement will be claimed only for approved meals served to eligible participants during the hours they are in attendance at approved child care homes. I understand that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. I understand that the submittal of false information in this document will result in the denial of my application and termination of my agreement to participate in the CACFP. I also understand that my sponsoring organization and all individuals providing false information in this document will be placed on the National Disqualified List (NDL) and will be subject to any other applicable civil or criminal penalties.

For TDHS Use Only

Approved

Denied (If checked, provide explanation below):

“EXHIBIT 1”

INFORMATION FOR CENTERS SPONSORED

County: _________________________

PUBLIC RELEASE FOR

CHILD AND ADULT CARE FOOD PROGRAM

______________________________________________________ announces

participation in (NAME OF SPONSORING ORGANIZATION)

the Child and Adult Care Food Program. Meals will be provided at no separate charge to eligible children served at the following site(s):

All meals will be provided in accordance with the U.S. Department of Agriculture non- discrimination policy which prohibits discrimination based on race, color, national origin, sex, age and disability. (Not all prohibited bases apply to all programs.)

The income eligibility guidelines for free and reduced price meals are attached.