FNS-828 030713 Revised - FNS-828

OMB APPROVED NO. 0584-0006
Expiration Date: 02/29/2016

UNITED STATES DEPARTMENT OF AGRICULTURE - Food and Nutrition Service

SCHOOL FOOD AUTHORITY PAID LUNCH PRICE REPORT
This form is for reporting SFA paid reimbursable lunch price data by each group of students.
STATE AGENCY NAME:

Enter the State Agency total number of SFAs:
Enter the school year (20XX-20XX):

Instructions: Please enter the most frequently charged price for each group of students. Students should be
grouped into the Elementary, Middle/Junior High, and High school categories as used within each SFA.
*For SFAs with no students in one of the above groups, please enter "N/A".
**For SFAs that do not charge a paid price for student lunches please enter "$0.00".
***State agencies must consolidate paid lunch prices reported by SFAs for the current school year and submit the
FNS-828 to FNS by the last operating day of November each year.
Public reporting burden for this collection of information is estimated to average 10 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. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of
Agriculture, Food and Nutrition Services, Office of Research and Analysis, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-xxxx*).
Do not return the completed form to this address.

Column 1

Column 2

Column 3

Column 4

SFA Name

Elementary

Middle/Junior High

High

Enter the name of the SFA

Enter the most frequently
charged paid price for
elementary school students
($X.XX).

Enter the most frequently
charged paid lunch price for
middle/jr high school students
($X.XX).

Enter the most frequently
charged paid lunch price for
high school students
($X.XX).

FORM FNS-828 (05-11) Previous Editions Obsolete

SBU

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