Private Schools: D - SFA Reimbursement Claims Data

OMB Approval No.: 0584-0530

Approval Expires:

NSLP AND SBP ACCESS, PARTICIPATION, ELIGIBILITY, AND CERTIFICATION STUDY (APEC-II)

SFA REIMBURSEMENT CLAIM VERIFICATION FORM

FOR ALL SCHOOLS

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 collection is 0584-0530. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collected.

N SLP AND SBP ACCESS, PARTICIPATION, ELIGIBILITY,

AND CERTIFICATION STUDY (APEC-II)

SFA REIMBURSEMENT CONSOLIDATION AND CLAIM VERIFICATION FORM

FOR ALL SCHOOLS

SFA ID: |___|___|___|___|___|___|___|___|

Date: | | | / | | | / | | |

MONTH DAY YEAR

Target Month From: | | | / | | | / | | | TO | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

IF CEO SCHOOL, ENTER REPORTED MEALS FOR FREE, PAID AND TOTAL ONLY.

IF NUMBER OF SCHOOLS REPORTED EXCEEDS TEN (10), USE ADDITIONAL FORMS TO RECORD INFORMATION.

PART A. MEAL CLAIMS FOR EACH SCHOOL FOR TARGET MONTH

Enter number of meals SFA claimed for each school.

Number of meals reported by the school to the SFA for School 1.	BREAKFASTS REPORTED	LUNCHES REPORTED
School 1 Name:	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |
Number of meals reported by the school to the SFA for School 2.	BREAKFASTS REPORTED	LUNCHES REPORTED
School 2 Name:	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |

Number of meals reported by the school to the SFA for School 3.	BREAKFASTS REPORTED	LUNCHES REPORTED
School 3 Name:	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |
Number of meals reported by the school to the SFA for School 4.	BREAKFASTS REPORTED	LUNCHES REPORTED
School 4 Name:	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |
Number of meals reported by the school to the SFA for School 5.	BREAKFASTS REPORTED	LUNCHES REPORTED
School 5 Name:	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |
Number of meals reported by the school to the SFA for School 6.	BREAKFASTS REPORTED	LUNCHES REPORTED
School 6 Name:	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |

Number of meals reported by the school to the SFA for School 7.	BREAKFASTS REPORTED	LUNCHES REPORTED
School 7 Name:	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |
Number of meals reported by the school to the SFA for School 8.	BREAKFASTS REPORTED	LUNCHES REPORTED
School 8 Name:	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |
Number of meals reported by the school to the SFA for School 9.	BREAKFASTS REPORTED	LUNCHES REPORTED
School 9 Name:	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |
Number of meals reported by the school to the SFA for School 10.	BREAKFASTS REPORTED	LUNCHES REPORTED
School 10 Name:	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |

PART B. SFA Consolidated Meal Claim – For All Schools in Target Month

Enter number of meals SFA claimed for all schools.

BREAKFASTS	LUNCHES
Free: | |,| | | |,| | | | Reduced: | |,| | | |,| | | | Paid: | |,| | | |,| | | | Total: | |,| | | |,| | | |	Free: | |,| | | |,| | | | Reduced: | |,| | | |,| | | | Paid: | |,| | | |,| | | | Total: | |,| | | |,| | | |

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