FNS 806-B Milk Claim for Reimbursement

OMB APPROVED NO. 0584-0284
Expiration Date: XX/XX/XXXX

U.S. Department of Agriculture Food and Nutrition Service
Milk Claim for Reimbursement
Please read the instructions on page 2 carefully before completing form.
1. Name and Address of Sponsor

2. Agreement Number

Name 1

3. Report Period

Addr 1

5. Claim Data

City
Zip

a. Number of sites participating

County

b. Number of days milk served

Contact

c. Enrollment

Tel

Year

4. Number of Operating Days

Addr 2
State

Month

Fax

d. Average Daily Attendance

E-Mail

e. Number of Free Approved
Amended

6. Number of half-pints served TO CHILDREN that were paid for by children in pricing program
and / or served at no charge to children in non-pricing program.
7. Number of half-pints served free TO CHILDREN eligible for free milk in pricing program.
8. Total number of ALL half-pints of milk purchased.
9. Total cost of ALL half-pints of milk purchased and reported in item 8 (round to the nearest dollar).
10. Average dairy cost (Item 8 / Item 9).
11. Total earning (Item 6 * Paid Rate + Item 7 * Item 10)(Automatically calculated).
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

Title

Preparation

FNS USE ONLY
Date

Date Processed

Approval Serial Number

Entry Date

Paylist Date

Paylist Number

*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-806B (12-09) Previous Editions Obsolete

SBU

Electronic Form Version Designed in Adobe 10.0 Version

U.S. Department of Agriculture Food and Nutrition Service
Milk Claim for Reimbursement
INSTRUCTIONS TO COMPLETE THE SPECIAL MILK CLAIM FOR REIMBURSEMENT.
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
The information for the claim should cover activities during the calendar month; however, you may include up to 10
operating days of the month before the first full month of operation and/or up to 10 operating days of the
month after the last full month of operation. The only EXCEPTION would be between school years. Since the
SCHOOL YEAR starts on July 1 of each year, the June claim should not include data for July of the following
school year, and the July claim should not include data for June of the previous school year. If the number of
operating days exceeds 31, please contact your Regional office for assistance.
The amount of money you receive will be based on reimbursement rates in effect for the month being reported.
If you have any questions about completing the claim form, please contact your Regional office for assistance. An
improperly completed form will delay processing of your reimbursement by electronic funds transfer (EFT).
SPECIFIC ITEMS
Check to be sure that all the information that automatically appears on the claim is correct. If the sponsor number or
name and address are missing or incorrect, immediately contact your Regional office to get corrections made.
3. Enter the month and year that this claim covers. For example, January 1999 would be entered as: Month 1 Year
1999
4. Enter the number of operating days in the month.
5.a. Enter the number of sites that are approved to participate in the milk program.
5.b. Enter the number of days milk was served in the claim month.
5.c. Enter the highest number of students enrolled in the institution for the month.
5.d. Average daily attendance (ADA) can be determined as follows: Total Daily Attendance for the Month / Days of
Operation (reported in item 4)
5.e. Enter the number of students approved for Free Milk.
SPECIAL NOTE: Use the highest number of children eligible for any given day of the month.
Items 6. - 11.
6. Enter the number of half-pints of milk you served at no charge to children in a non-pricing program, or served to
children not eligible for free milk in a pricing program during the month. DO NOT include half-pints of milk served to
children eligible for free milk according to your FREE MILK policy statement.
7. Enter the number of half-pints of milk served at no charge to children eligible for free milk in a pricing program.
DO NOT include milk served in a non-pricing program.
8. Enter the cost of ALL milk purchased for the claim month. This is the purchase price you paid to the milk supplier
for ALL milk delivered to your school/institution. DO NOT include any amount paid to the milk supplier for servicing,
rental or installment payments of milk service equipment.
9. Enter the total number of ALL half-pints of milk purchased during the claim month.
10. DO NOT enter information, it will be automatically calculated.
11. DO NOT enter information, it will be automatically calculated.
The claim must be signed and the Date of Preparation must be completed for payment to be disbursed.