State, Local, and Tribal Government - State Child Nutrition Agency, SFA, and Schools

APPENDIX B10. SFA REIMBURSEMENT CONSOLIDATION AND CLAIM VERIFICATION FORM—ALL SCHOOLS

OMB Number: 0584-0530

Expiration Date: XX/XX/XXXX

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

SFA REIMBURSEMENT CONSOLIDATION AND CLAIM VERIFICATION FORM—ALL SCHOOLS

SUMMARY:

The data collector will obtain and abstract meal count and claims data for the Target Month, which is the most recent calendar month in which meal count and claims data were submitted. In the rare instances in which the data for the Target Month is no longer available or accessible, the data collector will abstract data for the Target Week, which is the week prior to the data collection visit. In the even more rare instance in which the Target Week is not available, the data collector will collect the data for the Target Day, which is the day of the data collection visit.

Data will be entered into the SFA Reimbursement Consolidation and Claim Verification Form—All Schools on the computer, saved, and securely transmitted to the home office.

SFA meal claim data will be used to determine aggregation errors at the SFA level.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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 0584-0530. The time required for the SFA data manager to provide access to the SFA claim records is estimated to average 30 minutes per response during each data collection round, including the time to review instructions, search existing data resources, gather and maintain the data needed, and complete and review the collection of information.

SFA Name: _______________________________________________________

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

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

MONTH DAY YEAR

___________________________________________________________________________________________________________

Select ONE (Target Month, Target Week, or Target Day):

 Target Month: | | | / | | || | |

MONTH YEAR

 Target Week: | | | / | | | / | | | TO | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

 Target Day | | | / | | | / | | |

MONTH DAY YEAR

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

IF NUMBER OF SCHOOLS REPORTED EXCEEDS TEN (10), USE ADDITIONAL FORMS TO RECORD INFORMATION.

PART A. MEAL CLAIMS FOR EACH SCHOOL FOR TARGET MONTH (IF TARGET MONTH IS NOT AVAILABLE, ENTER TARGET WEEK OR TARGET DAY DATA)

Number of meals reported by the school to the SFA for School 1.	BREAKFASTS REPORTED	LUNCHES REPORTED
School 1 Name:	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |
Number of meals reported by the school to the SFA for School 2.	BREAKFASTS REPORTED	LUNCHES REPORTED
School 2 Name:	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |

Number of meals reported by the school to the SFA for School 3.	BREAKFASTS REPORTED	LUNCHES REPORTED
School 3 Name:	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |
Number of meals reported by the school to the SFA for School 4.	BREAKFASTS REPORTED	LUNCHES REPORTED
School 4 Name:	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |	Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |

*Add additional row for each additional school

PART B. SFA Consolidated Meal Claim – For All Schools in Target Month (IF TARGET MONTH IS NOT AVAILABLE, ENTER TARGET WEEK OR TARGET DAY DATA)

Enter number of meals SFA claimed for all schools.

BREAKFASTS	LUNCHES
Free: | |,| | | |,| | | | Reduced: | |,| | | |,| | | | Paid: | |,| | | |,| | | | Total: | |,| | | |,| | | |	Free: | |,| | | |,| | | | Reduced: | |,| | | |,| | | | Paid: | |,| | | |,| | | | Total: | |,| | | |,| | | |