Form FNS 806-A FNS 806-A School Lunch/Breakfast/Snack Claim for Reimbursement

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FORM APPROVED OMB NO. 0584-0284
EXPIRATION DATE: XX/XX/XXXX

U.S. Department of Agriculture Food and Nutrition Service
School Lunch/Breakfast Claim for Reimbursement
Please read the instructions on page 2 carefully before completing form.
Sponsor Number:

Claim Month/Year

Sponsor Name:

Phone:

Region #:

Address:

Fax:

County:

Amended

E-Mail:
City:

1. General Data

State:
Lunch

Person Preparing Claim:

Zip:
Reg Brk

SN Brk

Supplements

a. Number of schools participating

d. Average Daily Attendance

b. Number of days meals served

e. Number Approved for Free

c. Enrollment

f. Number Approved for Reduced

2. Student Lunch Participation and Reimbursement
Meals Served
Lunch

Rates

X
X
X

a. Paid
b. Reduced
c. Free

=
=
=
Subtotal

d. Total Student Lunches

3. Student Breakfast Participation and Reimbursement
Meals Served
Rates
Regular Breakfast
X
X
X

a. Paid
b. Reduced
c. Free

Severe Need Breakfast

Meals Served

a. Paid
b. Reduced
c. Free

=
=
=
Rates

Subtotal

X
X
X

=
=
=

d. Total Student Breakfasts

Subtotal

4. Student Supplements Participation and Reimbursement
Meals Served
Rates
Supplements

Subtotal

a. Paid
b. Reduced
c. Free

X
X
X

=
=
=

d. Total Student Supplements

Subtotal

5. Total Reimbursement
6. Total Cost for School Lunch and Breakfast Programs

Totals

I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, THIS CLAIM IS TRUE AND CORRECT IN ALL RESPECTS,
THAT RECORDS ARE AVAILABLE TO SUPPORT THIS CLAIM; THAT IT IS IN ACCORDANCE WITH THE TERMS OF EXISTING
AGREEMENT(S); AND THAT PAYMENT THEREFORE HAS NOT BEEN RECEIVED; I RECOGNIZE THAT I WILL BE FULLY
RESPONSIBLE FOR ANY EXCESS AMOUNTS WHICH MAY RESULT FROM ERRONEOUS OR NEGLECTFUL REPORTING HEREIN.
Signature of Authorized Representative

Date of Preparation

Notes

FORM FNS-806A (12/09) Previous Editions are Obsolete

SBU

Electronic Form Version Designed in Adobe 8.1 Version

Claim Submission Instructions
SPECIAL NOTE: AN ADJUSTED CLAIM completely voids all previous claims for the same month. Therefore, you should include ALL of your
reporting data for the entire month's operations.
General
You should use this claim form to report information for the National School Lunch and Breakfast Programs which are administered by the
Food and Nutrition Service, USDA. This information should cover activities during one calendar month; however, you may include up to 10
operating days of the month after the last full month of operation. The amount of money you receive will be based on reimbursement rates in
affect for the month being reported.
Complete only those sections of the claim form that apply to your operation. This claim will be returned to you and no payment will be made if
your claim is not properly completed. Therefore, be sure you sign and date this claim before submitting it to our Regional Office.
If you have any questions about how to complete an item on this claim form, please contact your Regional Office for assistance immediately.
An improperly completed form will delay processing of your reimbursement check.
SPECIFIC ITEMS Information at top of claim form - Check to be sure if the pre-printed information is correct. If the sponsor number or your
name and address are missing, please put in the proper information. If either or both are incorrect, immediately contact your Regional Office to
get corrections made. Enter the month and year that this claim covers. For example, January 1999 would be entered as 01 99. If this is a
revision of a previous claim, check the box marked "Amended".
General Data
1a., b., c. Enter the requested data for each program for which you participate and has been approved on your application approval.
1d. - Average daily attendance (ADA) can be determined as follows:
This is calculated by dividing Total Student Attendance for this Month by Days of Operation (NOTE: Use actual attendance counts. Do NOT
USE meal counts to determine attendance.)
1e., f. - Enter the number of children who had approved applications on file during the reporting month. (NOTE: Use the highest number of
children eligible for any given day of the month.) Make every effort to ensure this information is complete and accurate.
NOTE: For items 2 through 4 it is only necessary to enter the number of meals served by category. The rates, reimbursement by category,
total student lunches and total reimbursement will automatically be calculated.
2a., b., c. - Enter the number of lunches served for each category.
3a., b., c. - Enter the number of breakfasts served for each category for sites that are not approved for the Severe Need Breakfast Program
according to your application approval.
3d., e., f. - Enter the number of breakfasts served for each category for sites that are approved for the Severe Breakfast Program according to
your application approval. If no sites were approved for Severe Need this section should be blank.
4a., b., c - If you are approved to be reimbursed for supplements on your application approval, enter the number of supplements served by
category.
5. Total Reimbursement will be automatically calculated.
6. To be completed only if you have an approved severe need breakfast program. Enter the allowable costs for operating the National School
Lunch and School Breakfast Programs in your school or institution. Determine your costs in accordance with your Regional Office's Financial
Management instructions.
Sign and date the claim. An unsigned claim cannot be processed and payment will not be made.
Please mail to: National Child Nutrition Payment Center
USDA, Food and Nutrition Service
Mercer Corporate Park
300 Corporate BLVD.
Robbinsville, NJ 08691-1598
Public reporting burden for this collection of information is estimated to average .5 hours per response including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information.

FORM FNS-806A (12/09)