Form FNS-13 Annual Report of State Revenue Matching

FORM APPROVED OMB 0584-0075
U.S. DEPARTMENT OF AGRICULTURE
FOOD AND NUTRITION SERVICE

ANNUAL REPORT OF STATE REVENUE MATCHING
See Instructions on Reverse
Submit original to the Regional Administrator, Food and Nutrition Service, Retain one copy. Report must be submitted by October 31.
According to the Paperwork 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 0584-0075. The time required to complete this information collection
is estimated to average 80 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.
2A. STATE AGENCY

1. STATE

2B. AGENCY CODE (7 Digits)

NON-FEDERAL REVENUES

3. REPORT FOR SCHOOL YEAR ENDING 4. FINAL REPORT ("X" One)

June 30,

YES

NO

5. STATE REVENUES TO BE COUNTED TOWARD
THE STATE REVENUE MATCHING REQUIREMENT

(NOTE: Do not enter cents in Item 6. All amounts
must be rounded to nearest whole dollar.)
6. REMARKS

7. CERTIFICATION

I certify that this report is true and correct to the best of my knowledge and belief.
8. SIGNATURE

9. TITLE

Form FNS-13 (05-98) Previous editions are obsolete

10. DATE SIGNED

Electronic Form Version Designed in Adobe 7.1 Version

No further monies or other benefits may be paid out under these programs unless this report is
complete and filed as required by existing regulations (7 CFR - 210).

SBU

INSTRUCTIONS
PREPARATION AND DISTRIBUTION - Prepare in duplicate. Mail original to the
appropriate Regional Office. Retain one copy.
PURPOSE - This report provides data necessary to monitor the State Revenue
Matching Requirement under the National School Lunch Program (NSLP).
REPORTING PERIOD - The period covered by this report shall be the school year
(July 1 - June 30). The report must be mailed by October 31.
STATE AGENCY RESPONSIBILITIES - Each State agency is responsible for submitting
a report on "actual data." Further, the State agency must provide, at the request of
FNS, adequate corrections and/or clarifications on a timely basis.
All items are self-explanatory except.
ITEM 4 - If this is not a final report, indicate in the "Remarks" section why it is not the
final report and when the final report will be submitted.
ITEM 5 - Enter the amount of non-Federal revenue applicable to the State Revenue
Matching Requirement (SRMR). This refers to those revenues used specifically by
the State for school nutrition program purposes (NSLP, SBP, and SMP in schools) as
defined in the NSLP regulations and must be documented by an audit trail to ensure
that revenues provided are used for the stated purpose. For example: funds
appropriated by a State and used for reimbursing schools on a per-meal basis for
meals served could be counted in this item.