Attachment C: Form FNS-640 Administrative Review Data Report

Attachment C. Form FNS-640 Administrative Review Data Report

A1. General SFA Information

A2-1C. 99% Confidence
Level / Manual System

A2-1B. 95% Confidence
Level /Electronic Sysytem

A2-1A. 100%

A1-2. SFA Name

A1-4.
Review
Period
(Year)

A1-5. Total # Schools offering SBP

A1-1. SFA ID

A1.3.
Review
Period
(Month)

A2-1. Sampling Methodology
(Select [1] one)

A2-5D. Social Security #
(last 4 digits)
A2-5C. Income Amount or
Source

A2-5B. Case Number
A2-5A. Child or
Household Name

A2-4B. Reduced price

A2-4A. Free

A2-3B. Reduced price

A2-3A. Free

A2-2. Total # of Students Reviewed
(i.e. Sample Size #)

A2-3. SFA Count of
Reviewed Students (#)

A2. Certification and Benefit Issuance Review M
A2-4. SA Count of
Reviewed Students
(#)
A2-5. Application Errors by Type (#

Method

#)

A2-5E. Adult Signature

A2-6A. Free -> Reduced
Price

A2-6B. Free -> Paid

A2-6C. Reduced price ->
Paid

A2-6D. Reduced price ->
Free

A2-7A. Free -> Reduced
Price

A2-7B. Free -> Paid

A2-7C. Reduced price ->
Paid

A2-7D. Reduced price ->
Free

A3-1. NSLP Total
Overclaim/Underclaim ($ +/-)
A2-7. Total # of Benefit Issuance Errors
A2-6. Total # of Applications
Miscategorized

A4. Resource Management
A3. Fiscal Action

A4-1E. Indirect Costs
A4-1D. Revenue from
NonProgram Foods
A4-1C. Paid Lunch Equity
A4-1B. NonProfit School
Food Service Account
A4-1A. SFA Enrollment

A3-2. SBP Total
Overclaim/Underclaim ($+/-)

A3-3. Afterschool Snacks Total
Overclaim/Underclaim ($+/-)

A3-4. Was Overclaim Disregarded
(Select [1] if Yes)

A3-5. Were Funds Withheld or
Recovered (Select [1] if Yes)

A3-6. Underclaim paid to SFA ($)

A4-1. Risk Flag(s) Triggered (Select [1] all that apply)