Form FNS-66B Special Milk Program Application, Agreement Policy State

U.S. Department of Agriculture Food and Nutrition Service

Form Approved OMB# 0584-0005
Expiration Date: xx/xx/20xx

SPECIAL MILK PROGRAM APPLICATION, AGREEMENT POLICY STATEMENT
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is required to respond to, a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0584-0005. The time required to complete this information collection is estimated to average 15
minutes (.25 hours) per response, including the time for reviewing instuructions, searching existing data resources, gathering and maintaining the data needed, and completing and
reviewing the collection of information.

General

1. Name and Mailing Address of Sponsor

School Year:

Name

2. Name Address and Phone of Contact Person
Name

Sponsor Number:

Addr 1

Addr 1

County:

Addr 2

Addr 2

Region
Number:
3. Organization is

City
Private

State

City

Zip

Tel

Public Street Addr

4. Number of Sites by Sponsor Type
A. Day Schools
B. Boarding Schools
C. RCCIs
D. RCCIs w/ Day Students
E. Camps
F. Child care institutions
G. Other

5. Are you requesting the free milk program?
6. Planned period period of milk service
A. Begin Date

B. End Date

C. Estimated number of days milk
service will operate this year

D. Months for which claims will NOT be submitted
Jul
Jan

Aug
Feb

Sep
Mar

Oct
Apr

Nov
May

Dec
Jun

State

Zip

Fax:

EMail
7. Program data (estimate for school year)
A. Total number of schools / institutions
applying for participation
B. Total enrollment for sites participating
C. Price charged per 1/2 pint milk (daily)
D. Estimated number of children eligible
1. Paid
2. Free

8. Does the school / institution receive or expect to receive a total of $300,000 or more in federal funds this year?
9. Attach a copy of the license or confirmation letter for each residential child care site?
10. For Private RCCI's: Licensed Capacity?

Attached

11. Have you read the terms of the agreement under FNS - 67?

12. NEW APPLICANTS ONLY

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

A. Indicate the Sponsor's Federal Employer
Identification Number (F.E.I.D. No. The number used
to report federal withholding and social security.)

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

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

Attached

Attached

Form Approved OMB# 0584-0006

U.S. Department of Agriculture Food and Nutrition Service
SPECIAL MILK PROGRAM APPLICATION, AGREEMENT POLICY STATEMENT

Bank Name
Bank Account Name
Bank Account Number
Bank Address
City
Bank Routing Transit Number

State

Zip

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.

Not
Signature

Print Name
Last Modified By

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

Title
Last Modified Date

Date