I CERTIFY that the information on
this application is true to the best of my knowledge; that reimbursement
will be claimed only for meals or milk served to children; and that the
school does not discriminate on the basis of race, color,sex, national
origin, age or disability. I further understand that this information is
being given in connection with the receipt of Federal funds, and that
deliberate misrepresentation may subject me to prosecution under
applicable State and Federal criminal statutes.

Form FNS-66A (2-00)
Previous Edition Obsolete

Notes:

Date

Last Modified By

Last Modified Date

Title

Signature

Region Number

State

Field Office

DoD School

Bank
Name

Bank
Acct. Name

Bank
Acct. #

Bank
Address

City

State

Zip

Bank
Routing Transit #

Form Approved
OMB# 0584-0006

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 0584-0006. The Time required to complete this information is
.25 hour per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review
the information collection.

U.S. Department of Agriculture Food and Nutrition
Service

NATIONAL SCHOOL LUNCH, BREAKFAST, AND COMMODITY SCHOOL PROGRAM
APPLICATION

A. Indicate the Sponsor's Federal Employer Identification
Number (F.E.I.D.) usedto report federal withholding and social
security.)

B. Attach a copy of letter from IRS documenting tax-exempt
status..

Attached

C. Sponsors must provide
assurance of compliance with Title VI of Civil Rights Act of 1964 by
completing Civil Rights Compliance Questionnaire.

Attached

D. DUNS Number

15. NEW APPLICANTS ONLY:

14. I have read the terms of the agreement.

13. For private RCCI's: Licensed capacity?

Attached

12. Attach a copy of current license or confirmation letter for each
residentialchild care site.

11. Does the school / institution receive or expect to receive a
total of $500,000 or more in federal funds?

10. Paid rate only?

Lunch

Regular Brk

SN Brk

Reg. Snack

Area Elig Snack

A. Schools / institutions participating in each
category

B. Enrollment for schools participating in each
category.

C.
Highest Price charged per meal.

1. Full Price

2.
Reduced price

3.
Adult price

D. Estimated number of
children eligible by category

1. Full
Price

2. Reduced
price

3.
Free

9. Program data (estimate for agreement year)

Sold as Unit
(Pricing)

No
separate meal charge (Non Pricing)

Combination (Pricing and Non-Pricing)

8. Meals for students are:

A. Self-contained kitchen.

B. Base Kitchen.

C. Satellite / Receiving School / Institution.

D.
Central kitchen.

E. Vended meals.

7. Number of each food preparation method:

A. Beginning date:

B. Ending date:

C. Est. operating days this year:

D. Days in operation per week:

E. Months for which claims will not be submitted:

Jul Aug Sep Oct

Nov Dec

Jan Feb Mar Apr

May Jun

6. Planned period of food service : (Month/Day/Yr)

5. Commodity only sponsor?

4. Does sponsor contract with food management company?

A. Private Day School

B. Private Boarding School

C. Public RCCI

D. Private RCCI

E. Private RCCI w/ Day Students

F. Other

3. Number of sites by sponsor type:

Name

Addr1

Addr2

City

State

Zip

Tel:

Fax:

E-Mail

2. Name address and phone of contact person:

Addr1

Addr2

City

State

Zip

Street Addr

1. Mailing address of sponsor:

School Year

Sponsor Number

Sponsor Name

County

Abbeville Accomack Adair
Adams Aiken
Alamosa Albemarle Alexandria (city) Allegheny Allendale Amelia
Amherst Anderson Andrew
Appling Appomattox Arapahoe Archuleta Arlington Atchison Atkinson Audrain
Augusta Baca
Bacon Baker
Baldwin Bamberg Banks
Barnwell Barrow Barry Barton Bartow
Bates Bath
Beaufort Bedford Ben
Hill Bent Benton Berkeley
Berrien Bibb
Bland Bleckley Bollinger Boone
Botetourt Boulder Brantley
Bristol (city) Brooks Brunswick
Bryan Buchanan Buckingham Buena Vista (city) Bulloch Burke
Butler Butts
Caldwell Calhoun Callaway
Camden Campbell Candler
Cape Girardeau Caroline Carroll
Carter Cass
Catoosa Cedar Chaffee
Chariton Charles City Charleston Charlotte Charlottesville (city) Charlton Chatham
Chattahoochee Chattooga Cherokee Chesapeake (city) Chester Chesterfield Cheyenne Christian Clarendon Clark
Clarke Clay
Clayton Clear
Creek Clifton Forge
(city) Clinch Clinton Cobb Coffee Cole Colleton Colonial Heights (city) Colquitt Columbia Conejos
Cook Cooper
Costilla Covington (city) Coweta Craig Crawford Crisp
Crowley Culpeper Cumberland Custer Dade Dallas Danville
(city) Darlington Daviess Dawson
De Kalb Decatur Dekalb
Delta Dent
Denver Dickenson Dillon
Dinwiddie DOD Dodge Dolores Dooly
Dorchester Dougherty Douglas Dunklin
Eagle Early
Echols Edgefield Edmunds Effingham El
Paso Elbert Emanuel Emporia
(city) Essex Evans Fairfax
Fairfax (city) Fairfield Falls Church (city) Fannin Fauquier
Fayette Florence Floyd
Fluvanna Forsyth Franklin
Franklin (city) Frederick Fredericksburg (city) Fremont Fulton
Galax (city) Garfield Gasconade Gentry
Georgetown Giles Gilmer Gilpin Glascock
Gloucester Glynn Goochland
Gordon Grady
Grand Grayson Greene
Greensville Greenville Greenwood Grundy
Gunnison Gwinnett Habersham Halifax Hall Hampton Hampton
(city) Hancock Hanover Haralson
Harris Harrison Harrisonburg (city) Hart Heard Henrico Henry
Hickory Highland Hinsdale Holt
Hopewell (city) Horry Houston
Howard Howell Huerfano
Iron Irwin
Isle of Wight Jackson James
City Jasper Jeff Davis Jefferson Jenkins Johnson
Jones Kent
Kershaw King and Queen King George King William Kiowa Kit
Carson Knox La Plata Laclede Lafayette Lake
Lamar Lancaster Lanier
Larimer Las
Animas Laurens Lawrence Lee Lewis Lexington
Lexington (city) Liberty Lincoln
Linn Livingston Logan
Long Loudoun
Louisa Lowndes Lumpkin
Lunenburg Lynchburg (city) Macon Madison
Manassas Park(city) Maries Marion
Marlboro Martinsville (city) Mathews McCormick McDonald McDuffie McIntosh Mecklenburg Mercer Meriwether Mesa
Middlesex Miller Mineral
Mississippi Mitchell Moffat
Moniteau Monroe Montezuma
Montgomery Montrose Morgan
Murray Muscogee Nelson
New Castle New Kent New
Madrid Newberry Newport News (city) Newton Nodaway
Norfolk (city) Northampton Northumberland Norton (city) Nottoway Oconee
Oglethorpe Orange Orangeburg Oregon Osage Otero Ouray Ozark Page Park Patrick Paulding Peach
Pemiscot Perry Petersburg
Pettis Phelps Phillips
Pickens Pierce Pike Pitkin Pittsylvania Platte Polk Portsmouth (city) Powhatan Prince
Edward Prince George
Prince William Prowers Pueblo
Pulaski Putnam Quitman
Rabun Radford (city) Ralls Randolph
Rappahanock Ray Reynolds Richland Richmond Richmond (city) Rio Blanco Rio
Grande Ripley Roanoke Roanoke
(city) Rockbridge Rockdale Rockingham Routt
Russell Saguache Saline
Saluda San
Juan San Miguel Schley Schuyler
Scotland Scott Screven
Sedgwick Seminole Shannon
Shelby Shenandoah Smyth
Southampton Spalding Spartanburg Spotsylvania St.
Charles St. Clair St. Francois St.
Louis St. Louis
(city) Stafford Staunton (city) Ste. Genevieve Stephens Stewart
Stoddard Stone Suffolk
(city) Sullivan Summit Sumter
Surry Sussex
Talbot Taliaferro Taney
Tattnall Taylor Tazewell
Telfair Teller Terrell
Texas Thomas
Tift Toombs
Towns Treutlen Troup
Turner Twiggs Union Upson Vernon Virginia Beach (city) Walker Walton
Ware Warren
Washington Wayne Waynesboro
(city) Webster Weld Westmoreland Wheeler White
Whitfield Wilcox Wilkes
Wilkinson Williamsburg Williamsburg (city) Winchester (city) Wise Worth Wright Wythe York Yuma

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