Fns 724

APPENDIX

FNS-742 FORM

School Nutrition Dietary Assessment Study IV

(OMB No.: 0584-0527)

Project Officer: Fred S. Lesnett

Office: Office of Research and Analysis

Food and Nutrition Service Room 1014

3101 Park Center Drive Alexandria, VA 22302

Telephone: 703-605-0811

FAX: 703-305-2576

Email: [email protected]

[/NSERT STATE AGENCY NAME]

SFAID#

SFA NAME

SCHOOL FOOD AUTHORITY

TYPE OF SFA

D

Public

D Private

VERIFICATION SUMMARY REPORT

SCHOOL YEAR

I-I

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it contains a valid OMB control number. The valid OMB number for this

collection is 0584-0026. The time required to complete this information collection is 6 minutes per response, including the time to review instructions, search existing data resources, gather the data

needed, and complete and review the information collection.

I. Enrollment, Application and Eligibility Information

II.

Results of Verification, by Application Type

(Pre Verification)

1. Type of Free/Reduced Price Application Used

6.

Type of Verification Used

D Individual Student

D Household

D Both

D Basic DAlternate-Random DAlternate-Focused

D No Verifications Performed

Report items 2 through 5 as of the last

A.

B.

Items 7 through 11 are required and

A.FREE

B.FREE

C.

operating day in October

All Schools

Provision 2/3 Schools

are reported as of the date of

ELIGIBLE

ELIGIBLE

REDUCED

WHICH ARE NOT

completion of the verification process

based on

based on

PRICE

OPERATING A

(see instructions). /tern 12 is optional

FSITANFI

Incomel

ELIGIBLE

:: ..

BASE YEAR

and is reported as of February 15.

FDPIR

Household Size

2.

Number of schools and RCCls

Application

Application

(Categorically

(Income

operating the NSLP andlor SBP

Eligible)

Eligible)

3. Number of enrolled students with access

to the NSLP (or SBP for SBP only schools)

A.

B.

7.

No Change

# applications

# of Students

If. of Approved Applications

4. Total FREE ELIGIBLE reported

:

# students

,:

•••••••••

4-1. # approved as FREE ELIGIBLE who are not

t"

8.

Responded,

subject to verification (directly certified, homeless

..........

Changed to Free

# applications

liaison list, income-eligible Head start, pre-K Even

.......

,

start, residential students,;n RCCls, non-applicants

# students

approved bv local officials

.... :

..........

i

4-2. #approved as FREE ELIGIBLE based on FSI

9.

Responded,

# applications

TANF/FDPIR case number submitted on an

Changed to

application (Categorically Eligible)

Reduced Price

# students

4-3. # approved as FREE ELIGIBLE based on

10.

Responded,

# applications

income/household size information submitted on an

Changed to

application

Paid

# students

4-4. # FREE ELIGIBLES reported for Provision 2/3

11.

Did Not

# applications

Schools WHICH ARE NOT OPERATING A BASE

Respond

YEAR

# students

4. Total REDUCED PRICE ELIGIBLE

12.

Reapplied and

# applications

reoorted

5-1. # reduced price eligibles reported for Provision

Reapproved on

2/3 schools WHICH ARE NOT OPERATING A BASE

or Before Feb.15

# students

YEAR

FORM APPROVED OMB #0584-0026 Expiration Date 10/31/2006

FORM FNS-742 (2/04)

SBU

Electronic Form Version Designed in Adobe 7.1 Version

INSTRUCTIONS FOR COMPLETING THE SFA VERIFICATION SUMMARY REPORT

ALL SFAS WHICH OPERATE THE NATIONAL SCHOOL LUNCH PROGRAM (NSLP) AND/OR THE SCHOOL BREAKFAST PROGRAM (SBP) MUST COMPLETE THIS REPORT ANNUALLY EXCEPT: 1) SFAs which ONLY administer the program in Residential Child Care Institutions (RCCls) which do not have day students; 2) SFAs which claim for all schools based on claiming percentages established through a population survey; 3) SFAs which do not have any free or reduced price eligible students.

I. Enrollment, Application, and Approval Information (Pre-Verification)

1. Indicate the type of application used for students who are applying for Free/Reduced Price Meal benefits. Report Items 2 through 5 as of the last operating day in October.

2 - 3. Enter the TOTAL number of NSLP/SBP schools and the number of students with access to the NSLP (or the SBP if the SFA does not operate the NSLP) for the SFA in column A. If the SFA has schools which are operating under Provision 2/3 for lunch (or for breakfast if the SFA does not operate the NSLP) WHICH ARE' IN A NON-BASE YEAR, enter the number/enrollment of 1) the Provision 2/3 NON BASEYEAR lunch schools plus 2) any Provisio,n 2/3 NON E?ASE YEAR schools which only operate the SBP in Column B.

4. In Column A, enter the TOTAL NUMBER OF FREE ELIGIBLE STUDENTS that the SFA reported as of the last operating day in October.

4-1.ln Column A, enter the TOTAL NUMBER OF STUDENTS approved as FREE ELIGIBLE whose approval Is not SUbject to verification. This includes students who are directly certified based on information from the FSITANF/ FDPIR agency, children on the homeless liaison list, income eligible Head Start, pre-K Even Start, residential students in RCCls, and non-applicants who are approved by local officials. DO NOT INCLUDE the calculated number of free eligibles who are reported for Provision 2/3 schools which are not operating a base year. These are reported

in item 4-4 below.

4-2. In Column A, enter the TOTAL NUMBER OF STUDENTS approved as FREE ELIGIBLE based on a FSITANF/ FDPIR case number which was submitted on an application (Categorically Eligible Applications). In Column B, enter the TOTAL NUMBER OF APPROVED CATEGORICALLY ELIGIBLE APPLICATIONS on file.

4-3. In Column A, enter the TOTAL NUMBER OF STUDENTS approved as FREE ELIGIBLE based on household size and income information submitted on an application (Income Eligible - Free Applications). In Column B, enter the TOTAL NUMBER OF APPROVED INCOME ELIGIBLE - FREE APPLICATIONS on file.

4-4. Enter the TOTAL NUMBER OF FREE ELIGIBLES reported for Provision 2/3 schools which are not operating a base year in Column A. (This number is determined by adjusting the number of free eligibles in the base year for these schools to reflect current total enrollment.)

5. In Column A, enter the TOTAL NUMBER OF STUDENTS approved as REDUCED PRICE ELIGIBLE. In Column B, enter the TOTAL NUMBER OF APPROVED REDUCED PRICE ELIGIBLE APPLICATIONS on file.

5-1. Enter the TOTAL NUMBER OF REDUCED PRICE ELIGIBLES reported for Provision 2/3 schools which are not operating a base year in Column A. (This number is determined by adjusting the number of reduced price eligibles in the base year for these schools to reflect current total enrollment.)

II. RESULTS OF VERIFICATION

6. Indicate the type of verification process the SFA uses to comply with the requirements of 7 CFR 245.6a.

7 though 12. Enter the results of the verification process ~Y TYPE OF APPLICATION APPROVAL. Items 7 through 11 are required, and are reported as of the date of completion of verificCltip'n. For the purposes of this report verification is complete:

for households whose eligibility does not change: as of the date of the confirmation of eligibility by a reviewing official;

for households which do not appeal a change in eligibility: as of the first operating day following the last date for filing an appeal in response to a notice of change in eligibility;

for households which appeal a change in eligibility: as of the first operating day following a decision by the hearing official.

7. Enter the number of applications with no change in eligibility and the number of students on these applications, for each application type.

8. Enter the number of applications for which the eligibility was changed to FREE BASED ON DOCUMENTATION PROVIDED BY THE HOUSEHOLD,and the number of students on these applications, for each application type.

9. Enter the number of applications for which the eligibility was changed to REDUCED PRICE BASED ON DOCUMENTATION PROVIDED BY THE HOUSEHOLD,and the number of students on these applications, for each application type.

10. Enter the number of applications for which the eligibility was changed to PAID BASED ON DOCUMENTATION PROVIDED BY THE HOUSEHOLD, and the number of students on these applications, for each application type.

11. Enter the number of applications for which the eligibility was changed to PAID BECAUSE THE HOUSEHOLD DID NOT RESPOND, and the number of students on these applications, for each application type. NOTE:Report ALL applications for which the household did not respond, even if the students on the application continued to receive free or reduced price meals while being claimed as paid.

12. Enter the number of applications for households whose eligibility was changed to PAl D as a result of verification that resubmitted applications and were re-approved for either free or reduced-price meal benefits, and

the number of students on these applications, for each application type.