State/Local: D - SFA Reimbursement Claims Data

Third Access, Participation, Eligibility and Certification Study Series (APEC III)

rev062112 Attachment D.1-SFA Reimbursement Claim Verif Form-Month

State/Local: D - SFA Reimbursement Claims Data

OMB: 0584-0530

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OMB Approval No.: 0584-0530

Approval Expires:

NSLP AND SBP ACCESS, PARTICIPATION, ELIGIBILITY, AND CERTIFICATION STUDY (APEC-II)

SFA REIMBURSEMENT CLAIM VERIFICATION FORM

TARGET MONTH FOR SAMPLED SCHOOL



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 0584-0530. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collected.


N SLP AND SBP ACCESS, PARTICIPATION, ELIGIBILITY,

AND CERTIFICATION STUDY (APEC-II)

SFA REIMBURSEMENT CLAIM VERIFICATION FORM

TARGET MONTH FOR SAMPLED SCHOOL

Number Serving Days:

Breakfast Lunch

| | | | | |

SFA Name:

SFA ID: |___|___|___|___|___|___|___|___|

School Name:

School ID: |___|___|___|___|___|___|___|___|

Date: | | | / | | | / | | |

MONTH DAY YEAR

Target Month From: | | | / | | | / | | | TO | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

IF CEO SCHOOL, ENTER REPORTED MEALS FOR FREE, PAID AND TOTAL ONLY

PART A: BREAKFAST


REPORTED TO SFA BY SCHOOL

REPORTED TO STATE AGENCY BY SFA

Free: | | | |,| | | |

Reduced: | | | |,| | | |

Paid: | | | |,| | | |

Total: | | | |,| | | |

Free: | | | |,| | | |

Reduced: | | | |,| | | |

Paid: | | | |,| | | |

Total: | | | |,| | | |

COMPLETE FOR PROVISION 2 OR PROVISION 3 SCHOOL IN NON-BASE YEAR

ENTER THE CLAIMING PERCENTAGES USED:

BASE YEAR PERIOD USED:

| | | | %

FREE

| | | | %

REDUCED

| | | | %

PAID

YEARLY PERCENTAGES 1

MONTHLY PERCENTAGES 2

SPECIFY MONTH USED:

COMPLETE FOR CEO SCHOOL

ENTER THE CLAIMING PERCENTAGES USED:



| | | | %

FREE

| | | | %

PAID




PART B: LUNCH


REPORTED TO SFA BY SCHOOL

REPORTED TO STATE AGENCY BY SFA

Free: | | | |,| | | |

Reduced: | | | |,| | | |

Paid: | | | |,| | | |

Total: | | | |,| | | |

Free: | | | |,| | | |

Reduced: | | | |,| | | |

Paid: | | | |,| | | |

Total: | | | |,| | | |

COMPLETE FOR PROVISION 2 OR PROVISION 3 SCHOOL IN NON-BASE YEAR

ENTER THE CLAIMING PERCENTAGES USED:

BASE YEAR PERIOD USED:

| | | | %

FREE

| | | | %

REDUCED

| | | | %

PAID

YEARLY PERCENTAGES 1

MONTHLY PERCENTAGES 2

SPECIFY MONTH USED:

COMPLETE FOR CEO SCHOOL

ENTER THE CLAIMING PERCENTAGES USED:



| | | | %

FREE

| | | | %

PAID



PART C:

INTERVIEWER: The number of meals an SFA claims for a school may differ from what the schools report to the SFA because the SFA makes an error or because the SFA is correcting an error in the school’s meal counts.

1. COMPARE BREAKFAST COUNTS AND CLAIMS. First for breakfast, compare the SFA claims against the school reports for each meal type (free, reduced-price, paid, and total) for the target month. [Or for CEO schools, free, paid and total for the target month]. If they differ, then check the SFA records to see if there are any notes in the file indicating that the SFA corrected the school breakfast counts and document in the space provided below under “COMMENTS.”

COMMENTS:

2. COMPARE LUNCH COUNTS AND CLAIMS. Next for lunch, compare the SFA claims against the school reports for each meal type (free, reduced-price, paid, and total) for the target month. [Or for CEO schools, free, paid and total for the target month]. If they differ, then check the SFA records to see if there are any notes in the file indicating that the SFA corrected the school lunch counts and document in the space provided below under “COMMENTS.”

COMMENTS:

Prepared by Mathematica Policy Research Page 0

File Typeapplication/msword
File TitleAPEC-II SFA REIMBURSEMENT CLAIM VERIFICATION FORM TARGET MONTH FOR SAMPLED SCHOOL
SubjectForm
AuthorAlicia Leonard
Last Modified Bylywilliams
File Modified2012-06-27
File Created2012-06-21

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