FNS-143 Claim for Reimbursement

FORM APPROVED OMB NO. 0584-0041
U.S. DEPARTMENT OF AGRICULTURE
Food and Nutrition Service

PLACE "X" IN
BOX IF THIS IS
AN ADJUSTED
CLAIM

Check for accuracy and make any changes that are necessary.
1. AGREEMENT NO.
2. NAME AND ADDRESS OF SER VICE INSTITUTION

CLAIM FOR REIMBURSEMENT
SUMMER FOOD SERVICE PROGRAM
FOR CHILDREN
INSTRUCTIONS: Submit original and one copy to FNS Regional Office w hich administers your program not later than the 10th of the month
follow ing the month covered by the claim. A copy must be retained by the sponsor. Record all entries in the right most positions in the
boxes provided for each item.
3. MONTH COVERED
BY THIS REPORT

4. PERIOD COVERED BY THIS CLAIM (YOU MAY INCLUDE NO
MORE THAN 9 OPERATING DAYS OF THE MONTH PRECEDING
CLAIM MONTH AND/OR NO MORE THAN 9 OPERATING DAYS
OF MONTH FOLLOWING CLAIM MONTH.)

MONTH

YEAR

FROM:

5. TOTAL NUMBER
OF DAYS THIS
CLAIM PERIOD
FOOD SERVICE
WAS PROVIDED

6. AVERAGE DAILY NUMBER
OF ELIGIBLE CHILDREN SERVED

TO:

MONTH

DAY

YEAR

MONTH

FOOD SERVICE TO CHILDREN (Report only meals meeting requirements
in the Agreement.)

DAY

YEAR

PROGRAM COST DURING CLAIM PERIOD (Include all costs incurred
w hether or not payment w as actually made.)
DO NOT
KEY
PR 8 MC

7.

Total number of breakfasts served

8.

Total number of lunches served

12. Food

9.

Total number of suppers served

10. Total number of supplements served

0

0

13. Labor (Excluding Administrative
Costs)

0

0

14. Other (Excluding Administrative
Costs)

0

0

15. SUBTOTAL (Items
12+ 13+ 14)

0

0

16. Administrative Costs

0

0

17. TOTAL PROGRAM COSTS
(Items 15 + 16)

0

0

FUNDS RECEIVED DURING MONTH
11. All income specifically designated for FOOD
SERVICE including donations and payments
for meals from all sources except USDA.
DO NOT
KEY
PR 8 MC

FOR FNS USE ONLY
ADJOVR

Adjustment / Override Code
MONTH

DAY

YEAR

Official Submission Date

I CERTIFY that to the best of my know ledge and belief, this claim is true and correct in all respects, that records are available to
support this claim, that it is in accordance w ith the terms of existing Agreement(s); and that payment therefore has not been
received. I recognize that I w ill be fully responsible for any excess amounts w hich may result from erroneous or neglectful reporting
herein. I also understand that this information is being given in connection w ith the receipt of Federal funds; and that deliberate
misrepresentation may subject me to prosecution under applicable State and Federal criminal statutes. I further certify that all
claims for reimbursement shall be submitted to the Regional Office no later than the legislatively mandated deadline of 60 days
after the end of the claim period. I understand that failure to submit claims w ithin the 60 day deadline may result in such claims
not being paid.
DATE OF PREPARATION
MONTH

DAY

TITLE

SIGNATURE OF AUTHORIZED REPRESENTATIVE

YEAR

All receipts, invoices, and other evidence of purchase must be retained and
available for future audit for a period of 3 years after the date of submission
of the final claim for the fiscal year to w hich they pertain.
FORM FNS-143 (10-99) Previous editions obsolete

No further monies or other benefits may be paid out under the program unless
this report is completed and filed as required by existing regulations (7 C.F.R.
225)
Electronic Form Version Designed in JetForm 5.01 Version

INSTRUCTIONS
SPECIAL NOTE:

An ADJUSTED CLAIM FOR REIMBURSEMENT completely voids all previously submitted
claims for the same month. Therefore, you must include ALL of your reporting data for
the entire month' s operations.

This information should cover activities during one calendar month; how ever, you may include no more than 9 operating days of the month
before the first full month of operation and/or no more than 9 days of the month after the last full month of operation. Amount of reimbursement
w ill be computed by USDA, based on rates in effect.

YOUR CLAIM WILL BE RETURNED FOR CORRECTION IF NOT PROPERLY COMPLETED. BE SURE TO SIGN
THIS CLAIM BEFORE MAILING TO AVOID DELAYING YOUR REIMBURSEMENT CHECK.
ITEM (all items self-explanatory unless noted below )
3. Enter the number of the month and year this claim covers.
Example: June 1988 =

0

6

1

9

8

8

5. Enter the number of days during the claimperiod in w hich meal service w as provided at one or more sites.

6. Compute by adding the total number of eligible children served w atch day by all sites to get a cumulative total number of eligible children
served for the claim period, and dividing by the number of days of operation for the same claim period. (Item 5.)
11. Enter total amount of fund received for food service from individual donations. State and local contributions, payments for adult meals,
and reimbursement from other Federal programs. (DO NOT INCLUDE "start-up funds", "advance payments", and "monthly reimbursement
payments" from this USDA program or loans to the program.)

12. Enter all food costs including milk. Such costs shall include, in addition to the purchase price, the cost of processing, distributing,
transporting, storing, or handling of any purchased or donated food including USDA donated commodities. (DO NO INCLUDE the
value of donated food.)

13. Enter labor costs w hich include all w ages earned in connection w ith the food preparation, delivery and service, include costs incurred
during the month covering payroll deduction for social security, w ithholding tax, insurance, retirement, etc., as w ell as employer' s
contribution during the month for employee benefits.

14. Enter program costs other than for food, labor and administrative. These costs include service costs e.g., rental fees for food service
facilities, rental or use allow ance of food service equipment, repairs to equipment eligible for use allow ance, and utilities, and cost of
supplies used e.g., cleaning materials, paper plates, plastic eating utensils, straw s. (DO NOT INCLUDE costs reported in item 12
and 13.)

16. Enter administrative costs related to planning, organizing and managing the Program, and rental cost of office space and equipment.
DO NOT INCLUDE interest costs and costs for purchase of land, buildings and equipment.)

REVIEW YOUR ENTRIES, WHEN YOU ARE SATISFIED THEY ARE TRUE AND CORRECT TO THE BEST OF YOUR KNOWLEDGE,
SIGN THE CLAIM, ENTER YOUR TITLE AND THE DATE CLAIM WAS PREPARED.

According to the Paperw ork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0041. The time
required to complete this information collection is estimated to average 30 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection.

FORM FNS-143 (REVERSE)

Electronic Form Version Designed in JetForm 5.01 Version