Fns 66a National School Lunch, Breakfast, And Commodity School P

OMB APPROVED NO. 0584-0006
Expiration Date: XX/XX/XXXX

Print

Department of Agriculture, Food and Nutrition Service
NATIONAL SCHOOL LUNCH, BREAKFAST, AND COMMODITY SCHOOL PROGRAM APPLICATION
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 1.30 hour per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
School Year:

Sponsor Number:

Sponsor Name:

County:

Region Number:

State:

Field Office:

DoD School:

1. Mailing address of sponsor:
Address 1
Address 2
City

State

Zip Code

City

State

Zip Code

Telephone

Fax Number

Street Address
2. Name and address and phone of contact person:
Name
Address 1
Address 2

E-Mail
3. Number of sites by sponsor type:
A. Private Day School

D. Private RCCI

B. Private Boarding School

E. Private RCCI w/Day Students

C. Public RCCI

F. Other

4. Does sponsor contract with food management company?
Yes

No

5. Commodity only sponsor?
Yes

No

6. Planned period of food service:
A. Beginning date

E. Months for which claims will not be submitted

B. Ending date
C. Estimate operating days this year

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

D. Days in operation per week
7. Number of each food preparation method:
A. Self-contained kitchen

C. Satellite / Receiving School / Institution

B. Base Kitchen

D. Central Kitchen

E. Vended meals

8. Meals for students are:
Sold as Unit (Pricing)
No separate meal charge (Non Pricing)
Combination (Pricing and Non-Pricing)
FORM FNS-66A (03-12) Previous Editions Obsolete

SBU

Electronic Form Version Designed in Adobe 9.1 Version

9. Program data (estimate for agreement year)
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
10. Paid rate only?
No

Yes

11. Does the school / institution receive or expect to receive a total of $500,000 or more in federal funds?
No

Yes

12. Attach a copy of current license or confirmation letter for each residential child care site.
Attached
13. For private RCCI's: Licensed capacity?
14.

I have read the terms of the agreement

15. NEW APPLICANTS ONLY:
A. Indicate the Sponsor's Federal Employer Identification Number (F.E.I.D.) used to 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
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.
Title
Signature
Print Name
Date

Last Modified By

Last Modified Date

Notes

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

State

Zip Code