Form FNS-843 Report of Disqualification from Participation-Institutio

OMB APPROVED NO. 0584-0000
Expiration Date: XX/XX/XXXX

Department of Agriculture, Food and Nutrition Service

REPORT OF DISQUALIFICATION FROM PARTICIPATION INSTITUTION AND RESPONSIBLE PRINCIPALS/INDIVIDUALS
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it contains
a valid OMB control number. The valid OMB number for this collection is 0584-XXXX. The time required to complete this information
collection is 30 minutes per response, including the time to review instructions, to search existing data resources, to gather the data
needed, and to complete and review the information collection.
Section 243(c) of Public Law 106-224, the Agricultural Risk Protection Act of 2000, amended § 17(d)(5) of the Richard B. Russell
National School Lunch Act (42 U.S.C. 1766 (d)(5)(E)(i) and (ii)) by requiring the Department of Agriculture to maintain a list of
institutions, day care home providers, and individuals that have been terminated or otherwise disqualified from Child and Adult Care
Food Program (CACFP) participation. The law also required the Department to make the list available to State agencies for their use in
reviewing applications to participate and to sponsoring organizations to ensure that they do not employ as principals any persons who
are disqualified from the Program. This statutory mandate has been incorporated into § 226.6(c)(7) of the CACFP regulations.
Instructions: Within the National Disqualified List web-based system, users click on “Add Institution” on the task bar to add the
disqualification information of an institution and the responsible principals/individuals (RPI). When adding an institution and RPIs, fields
that are marked with an “*” are required to be completed in order to save the record.
Upon entering the address, users click on “Validate Address”. If the system does not recognize the address, an error message is
displayed and the user must alter the address or override the validation.
Select at least one disqualification reason. If “Other” is selected, it must be explained in the “Additional Comments” section.
Enter all of the RPIs. If there is a debt associated with the institution, at least one of its RPI is responsible for the debt.
If the entered data passes all validations, the institution and RPI information is saved into the system when the “Save” button is clicked.
After saving the information, State agency users cannot edit the information. If any changes need to be made to the saved record, State
agency users must contact the FNS Regional Office to modify the record. After successfully saving the record, the status of the newly
added institution and associated RPIs record is set to “Pending Review”. It will display this status until the FNS Regional Office
approves the record for inclusion on the NDL.

FORM FNS-843 (05-13) Previous Editions Obsolete

SBU

Electronic Form Version Designed in Adobe 10.0 Version

Institution
Institution Name:

Type of Institution:

Federal Employee Identification Number:

DUNS Number:

Street Number:

Additional Address Information:

Street Name/PO Box Number:

City:

State/Province:

Zip Code:

Other Business Names: (Please enter other business names below)

Note: Users have the ability to validate the address
within the National Disqualified List web-based system.

Disqualification Information
State Agency Imposing Disqualification:

Region:

Termination Date:

Debt Owed:
Yes

Original Debt Amount: (Please enter the amount in U.S. dollars)

No

Amount Paid: (Please enter the amount in U.S. dollars)

Date Debt Paid in Full:

Disqualification Reasons: (Please select one or more disqualification reasons as applicable)
Submission of false information on the institution's application, including but not limited to a determination that the institution has concealed a conviction for any activity
that occurred during the past seven years and that indicates a lack of business integrity. A lack of business integrity includes fraud, antitrust violations, embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false statements, receiving stolen property, making false claims, obstruction of justice, or any other
activity indicating a lack of business integrity as defined by the State agency.
Failure to operate the Program in conformance with the performance standards set forth in paragraphs (b)(1)(xviii) and (b)(2)(vii) of this section.
Failure to return to the State agency any advance payments that exceeded the amount earned for serving eligible meals, or failure to return disallowed start-up or
expansion payments.
Failure to adjust meal orders to conform to variations in the number of participants.
Claiming reimbursement for a significant number of meals that do not meet Program requirements.
Failure of a sponsoring organization to disburse payments to its facilities in accordance with the regulations at §226.16(g) and (h) or in accordance with its management plan.
Claiming reimbursement for meals served by a for-profit adult day care center during a calendar month in which less than 25 percent of its enrolled adult participants
were title XIX or title XX beneficiaries.
Failure by a sponsoring organization to properly train or monitor sponsored facilities in accordance with §226.16(d).
Use of day care home funds by a sponsoring organization to pay for the sponsoring organization's administrative expenses.
Failure to properly implement and administer the day care home termination and administrative review provisions set forth at paragraph (l) of this section and §226.16(l).
Conviction of the institution or any of its principals for any activity that occurred during the past seven years and that indicates a lack of business integrity. A lack of
business integrity includes fraud, antitrust violations, embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, receiving
stolen property, making false claims, obstruction of justice, or any other activity indicating a lack of business integrity as defined by the State agency.
Permitting an individual who is on the National disqualified list to serve in a principal capacity with the institution or, if a sponsoring organization, permitting such an
individual to serve as a principal in a sponsored center or as a day care home.
Failure to comply with the bid procedures and contract requirements of applicable Federal procurement regulations.
Failure to maintain adequate records.
Claiming reimbursement for meals not served to participants.
Use of a food service management company that is in violation of health codes.
Claiming reimbursement for meals served by a for-profit child care center or a for-profit outside-school-hours care center during a calendar month in which less than 25
percent of the children in care (enrolled or licensed capacity, whichever is less) were eligible for free or reduced-price meals or were title XX beneficiaries.
Failure by a sponsoring organization of day care homes to properly classify day care homes as tier l or tier ll in accordance with §226.15(f).
Failure to perform any of the other financial and administrative responsibilities required by this part.
The fact the institution or any of the institution's principals have been declared ineligible for any other publicly funded program by reason of violating that program's
requirements. However, this prohibition does not apply if the institution or the principal has been fully reinstated in, or is now eligible to participate in, that program,
including the payment of any debts owed.
Any other action affecting the institution's ability to administer the Program in accordance with Program requirements.
Other

Comments

Responsible Principals/Individuals:
RPI 1:
First Name:

Middle Name:

Last Name:

Date of Birth:

Title:

Program Debt:
Yes
No

Street Number:

Street Name/PO Box Number:

City:

Additional Address Information:
State/Province:

Note: Users have the ability to validate the address within
the National Disqualified List web-based system.

Other Names: (Please enter other names below.)
First Name:

Zip Code:

Middle Name:

Last Name:

Note: Users may add and remove individuals prior to saving the record within the NDL web-based system.