Form Isbe 69 23 – Fill Out and Use This PDF

INSTRUCTIONS: Complete all information below and return to the above address.

1. NAME OF SPONSOR OR SPONSORING ORGANIZATION		2.	COUNTY		3. FEIN NUMBER
ADDRESS (Street, City, State, Zip Code)		4.	MAILING ADDRESS (Street, City, State, Zip Code)
			(If mailing address is the same as physical address, leave blank)
5. NAME OF AUTHORIZED REPRESENTATIVE (First, Last)		TITLE			BIRTH DATE (mm/dd/yyyy)
TELEPHONE (Include Area Code and Ext.)	FAX (Include Area Code)			E-MAIL
6. NAME OF CONTACT PERSON (First, Last)		TITLE			BIRTH DATE (mm/dd/yyyy)
TELEPHONE (Include Area Code and Ext.)	FAX (Include Area Code)			E-MAIL

7. ELIGIBILITY

Public Entity (Complete numbers 8 and 9)

Not-For-Proit, (IRS) Federal Tax-Exempt conforming to the original ruling from the Internal Revenue Service (IRS)

(Complete numbers 8 and 9)

Private For-Proit Check (3) box below

	Corporation (Complete numbers 8 and 9)	Sole Proprietorship (Complete number 8 only)
8. EXECUTIVE DIRECTOR			9. CHAIRPERSON OF THE BOARD
Name	________________________________________		Name	________________________________________
Birth Date	________________________________________		Birth Date	________________________________________
	(mm/dd/yyyy)			(mm/dd/yyyy)
Mailing Address _______________________________________			Mailing Address _______________________________________
	(Street, City, State, Zip Code)			(Street, City, State, Zip Code)
	_______________________________________			_______________________________________

10. Select the organization type that best describes your organization:

State or Local Government Educational Institution

Non-Proit Organization (Secular, non-religious)

Non-Proit Organization (Faith-based, associated with a place of worship or certain religion

Other: _______________________________________________________________________________________________

11. Training on CACFP Requirements must be conducted prior to participation for key staff with CACFP responsibilities from every facility. Key staff includes the owner of a private, for-proit child care center, director, cook, and persons with CACFP record keeping

responsibilities. At a minimum, such training must include instruction, appropriate to the level of staff experience and duties, on the meal pattern requirements, completing meal counts, claims submission, and other recordkeeping requirements.

12. Training on Civil Rights requirements must be documented prior to participation.

Yes	No	We certify that all frontline staff have been trained on civil rights requirements. Date: _____ / ______ (mm/yyyy)
		If no, date training will be conducted _____ / ______ (mm/yyyy)

For more information on civil rights requirements in federally-assisted programs, as well as training content, visit http://www.isbe.net/nutrition/htmls/civil_rights.htm

ISBE 69-23 (12/12)

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13. Commodity-Sponsor Elects

The box you mark is a vote for that option. The majority of votes determines the option that will be provided to all institutions in the state.

Cash in lieu of government-donated commodities

Government-donated commodities

14. Multi-State organizations –

Does your organization operate the Child and Adult Care Food Program in other states?

Yes	No If yes, provide the full name of the cognizant state: ________________________________________________

15. Audit Information

During this calendar year, what is the end date of your organization's iscal year? Date: _________________ (mm/dd/yyyy)

For Proits (initial) ____ I agree to allow the Illinois State Board of Education auditing staff or its contractors to conduct program

speciic audits for this for-proit organization.

16. DUNS Number: ___ ___ ___ ___ ___ ___ ___ ___ ___ Dun and Bradstreet – Data Universal Numbering System (DUNS) number. If you do not have a DUNS number, please contact Dun & Bradstreet at http://fedgov.dnb.com/webform. For more information call

1-866-705-5711. Participating institutions are required to have and provide their DUNS number.

17.	Yes	No Will your organization expend $500,000 or more in federal funds during your organization's established iscal year?
			(Not applicable for Private For-Proit institutions.)
	Yes	No	Do you agree to send this agency a copy of your organization's A-133 single audit, program speciic audit or
			appropriate written documents as speciied in OMB Circular A-133 within 30 days after receipt of auditor's report or
			within nine months of the end of the iscal year, whichever is earlier? (Not applicable for Public Entities and Private
			For-Proit institutions.)
	Yes	No	Do you agree to submit a copy of the A-133 Audit to the Federal Audit Clearinghouse? (Not applicable for Public
			Entities and Private For-Proit institutions.)

18.Indicate or list publicly funded programs your institution has (and key individuals who have) participated in during the past seven years.

Illinois State Board of Education – Child and Adult Care Food Program or other funding

Illinois Department of Human Services – Subsidized Child Care beneits, Head Start or other funding

Department of Children and Family Services – Protective Care or other funding

Other: ________________________________________________________________________________________________

Other: ________________________________________________________________________________________________

I certify that neither the institution nor any of its key individuals have been convicted during the past seven years of any activities that indicate a lack of business integrity. Lack of business integrity includes fraud, antitrust violations, embezzlement, theft, forgery, bribery, falsiication

or destruction of records, making false statements, receiving stolen property, making false claims, obstructing justice, or any other activities indicating a lack of business integrity as deined by the State Agency. Any institution or individual providing false certiications will be placed on the National Disqualiied List and will be subject to any other applicable civil or criminal penalties.

_______________________________ _______________________________________________ ____________________________

Date

Original Signature of Authorized Representative

Title

ISBE USE ONLY

CACFP OPERATING APPROVAL DATES:

Beginning Date ______________________ Ending Date _________________________

ISBE 69-23 (12/12)

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