Fns 66 Application For Participation In The National School Lun

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OMB APPROVED NO. 0584-0006
Expiration Date: XX/XX/XXXX
U.S. DEPARTMENT OF AGRICULTURE

AGREEMENT NO.

FOOD AND NUTRITION SERVICE

APPLICATION FOR PARTICIPATION
STATE COUNTY

SFA CODE

OUTLET NO.

CHECK NO.

National School Lunch, School Breakfast
Special Milk, and Commodity School Programs
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 collection is estimated to average 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.
Through the National School Lunch Program, participating schools which operate nonprofit lunch programs in
accordance with 7 CFR Part 210 receive cash and donated food assistance. Participating schools in the Commodity
School Program receive donated food assistance in lieu of general cash assistance. Through the School Breakfast
Program, cash and donated food assistance are provided to participating schools which operate nonprofit breakfast
programs in accordance with 7 CFR Part 220. The Special Milk Program provides cash assistance to participating
schools which operate nonprofit milk service programs in accordance with 7 CFR Part 215. Participation in the Special
Milk Program is limited to those schools which 1) do not participate in US Department of Agriculture (USDA) meal
service programs or 2) operate split session kindergarten programs in which children do not have access to a USDA
meal service program.

INSTRUCTIONS: Type or print clearly all information. Every School Food Authority (SFA) must complete the FNS-66 in
duplicate; send the original to the Food and Nutrition Service Regional Office (FNSRO), and keep the duplicate for files.
Any SFA which administers two or more schools must complete a separate Section II for each school under its
jurisdiction.
SECTION I (For ALL SFAs)

1. NAME AND MAILING ADDRESS OF SFA, Include ZIP code
and street address, if it differs from the mailing address.

2. SFA REPRESENTATIVE. Provide the name and title of the
SFA official who will sign the agreement (FNS-67)

3. TERMS OF AGREEMENT. Check that you have read the
terms of agreement under the FNS-67.
TELEPHONE NO. (

)

4. ADMINISTERED SCHOOLS. Provide the total number of
schools which the SFA administers.

5. STUDENT ENROLLMENT. Indicate the total number of
students enrolled at ALL participating schools

6. PROGRAM APPLICATION. Specify the number of schools
applying for participation in each program.

7. ELIGIBILITY. Estimate the number of children at all
participating schools who may be eligible in each benefit
category.

PROGRAM

NUMBER OF
SCHOOLS

MEAL

SCHOOL BREAKFAST PROGRAM (SBP)

BREAKFAST

NATIONAL SCHOOL LUNCH PROGRAM (NSLP)
SERVING LUNCH

LUNCH

REDUCED
PRICE

PAID

AFTERSCHOOL
CARE SUPPLEMENT

SERVING LUNCH AND SUPPLEMENT
SPECIAL MILK PROGRAM (SMP)

MILK

COMMODITY SCHOOL PROGRAM (CSP)

COMMODITY

FORM FNS-66 (02-00) Previous Editions Obsolete

FREE

SBU

Electronic Form Version Designed in Adobe 9.1 Version

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DEFINITIONS
BASE KITCHEN means a food preparation facility located within a school where meals are prepared for
on-site consumption, and for delivery and serving at other schools.
CENTRAL KITCHEN means a food preparation facility where all meals are prepared for delivery and
serving off-site.
ELECTRONIC FUNDS TRANSFER refers to the method used for direct deposit of payments.
ENROLLMENT means the number of children enroled in a school who have access to the NSLP or SBP.
FREE MILK means milk served without any charge to a child whose household was determined eligible to
receive benefits in accordance with 7 CFR Part 245.
NONPRICING PROGRAM refers to a school in which no separate identifiable charge is made for meals
or milk served to children.
NONPROFIT when applied to shcools or institutions, means exempt from income tax under Section 501
(c)(3) of the Internal Revenue Code of 1986; or in the Commonwealth of Puerto Rico, certified as such by
the Governor.
NONPROFIT SCHOOL FOOD SERVICE means all food service operations conducted by the SFA
principally for the benefit of school children, through which all revenue must be used for the operation or
improvement of the food service.
OFFER VERSUS SERVE refers to the provision which allows children to decline up to two of the five
required food items offered in the reimbursable lunch, and one of the four required food items offered in
the reimbursable breakfast. However, the school must offer all required food items to all children.
PRICING PROGRAM means a school in which a sepatate identifiable charge is made for meals or milk
served to children.
SCHOOL is defined as one the following:
(a) An educational unit of high school grade or under, recognized as part of the educational system in the
State and operating under public or nonprofit private ownership in a single building or complex of
buildings;
(b) Any public or nonprofit private classes of preprimary grade when they are conducted in the
aforementioned schools;
(c) Any public or nonprofit private residential child care institution, or distinct part of such institution, which
operates principally for the care of children and, if private, is licensed to provide residential child care
services under the appropriate licensing code by the State or a subordinate level of government, except
for residential summer camps which participate in the Summer Food Service Program, Job Corps centers
funded by the US Department of Labor, and private foster homes. The term "residential child care
institutions" includes, but is not limited to homes for the mentally, emotionally, or physically impaired;
homes for unmarried mothers and their infants; group homes; halfway houses; orphanages; temporary
shelters for runaway children; juvenile detention centers; and long-term care facilities for chronically ill
children, i.e., a hospital, skilled nursing facility, intermediate care facility, or distinct part thereof, which is
intended for the care of children confined for 30 days or more;
(d) Any nonprofit child care center in the Commonwealth of Puerto Rico which is certified as such by the
Governor of Puerto Rico.
SCHOOL FOOD AUTHORITY means the governing body which is responsible for the administration of
one or more schools and has the legal authority to operate the programs therein or be otherwise
approved by FNS to operate the programs. Although an SFA may delegate authority to operate school
food service to another organization, the SFA must retain responsibility for full compliance with
regulations.
SEVERE NEED RATES are the rates of reimbursement in excess of the prescribed rates. Under the
SBP, schools whose documented operating costs exceed the prescribed rates may be eligible for severe
need rates if they have participated in the NSLP during the previous 2 years, and if at least 40 percent of
the lunches served during the second preceding school year were served to children eligible for free or
reduced price meals.

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SECTION II (For EACH School)
1. NAME AND ADDRESS OF SCHOOL

2. NAME AND TITLE OF FOOD SERVICE PROGRAM MANAGER

TELEPHONE NO. (

3. STATUS OF SCHOOL. Indicate if the school is public or
private. If the school is private, attach documentation of tax
exemption and licensing, as applicable.

PUBLIC
SCHOOL

)

4. TYPES OF SCHOOLS AND PROGRAMS. After identifying the
type of school or institution, specify in which programs you are
applying for participation.

PRIVATE
SCHOOL

STATUS OF SCHOOL

PROGRAM

NONPROFIT

SCHOOL

LICENSED

NSLP

SBP

SMP

CSP

NON-RESIDENTIAL SCHOOL

5. PLANNED PERIOD OF OPERATION. Estimate the number
of days food service will operate this school year.

NON-RESIDENTIAL CHILD
CARE INSTITUTION
RESIDENTIAL INSTITUTION
WITH DAY STUDENTS

STARTING DATE

RESIDENTIAL INSTITUTION
WITH NO DAY STUDENTS

ENDING DATE

CAMP

OPERATING DAYS

SERVICE INSTITUTION
(Nonprofit Sponsor)

6. ENROLLMENT DATA. Specify the number of children by age, 7. ELIGIBILITY. Estimate the number of children who may be
enrolled this school year. Enter the total.
eligible in each benefit category.

AGE

NUMBER OF
CHILDREN

MEAL

UNDER 5 YEARS

BREAKFAST

5 TO 8 YEARS

LUNCH

9 TO 11 YEARS

AFTERSCHOOL
CARE SUPPLEMENT

OVER 12 YEARS

REDUCED
PRICE

PAID

MILK

TOTAL

COMMODITY

8. FOOD SERVICE SCHEDULE. Indicate the time when meals
or milk will be served.

MEALS

FREE

BEGINNING

9. OFFER VERSUS SERVE. Check if "Offer Versus Serve" will
be available to some or all children at this school. Indicate
which grade levels will have this option.

SOME

ENDING

BREAKFAST

SBP

LUNCH

NSLP

ALL

GRADES

AFTERSCHOOL
CARE SUPPLEMENT
MILK
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10. FOOD PREPARATION. Identify the type of service or facility
which will be used by the school for food preparation.
Attach a copy of the contract or agreement, if applicable.

11. PRICES. Specify how much children will be charged for the
pruchase of meals or milk.
DAILY
REDUCED
PAID
PRICE

ON-SITE KITCHEN

BREAKFAST

BASE KITCHEN

LUNCH

CENTRAL KITCHEN
PRIVATE FOOD SERVICE MANAGEMENT COMPANY

SUPPLEMENT

PUBLIC SCHOOL CONTRACT

MILK

12. FOOD SERVICE INCOME. In addition to the NSLP, SBP,
SMP, or CSP, indicate if this school will provide any food
service in which the revenue will not accrue to the nonprofit
school food service account.
YES

WEEKLY
REDUCED
PAID
PRICE

13. SEVERE NEED BREAKFAST. Check if you wish to apply for
severe need rates for this school under the SBP.

NO

SECTION III (For Special Milk Program Applicants ONLY)
TYPE OF SMP PROGRAM. Indicate whether the SMP will be operated in your school as a pricing and/or nonpricing program.
While there are no separate charges for milk in a nonpricing program, separate charges are made in pricing programs. Note that
dual participation in a USDA meal service program and the SMP is prohibited, although schools which operate split session
kindergarten programs may apply to the SMP to provide milk for children who do not have access to the meal programs.
ESTIMATED PARTICIPATION
KINDERGARTEN
AND PRESCHOOL
AGED CHILDREN

SCHOOL
AGED
CHILDREN

ELIGIBLE
FREE
CHILDREN

HALF PINTS
SERVED PER
CHILD PER DAY

ADULTS

NON-PRICING
PRICING, CHOODING TO DETERMINE
ELIGIBILITY FOR FREE MILK
PRICING, CHOODING NOT TO DETERMINE
ELIGIBILITY FOR FREE MILK
COMBINATION
(Pricing and Nonpricing)

CERTIFICATION STATEMENT

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 subject me to prosecution under applicable State
and Federal criminal statutes.
DATE

SIGNATURE OF SCHOOL OR SFA OFFICIAL

TITLE

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