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

APPENDIX B16. (INSTRUMENT D3). SFA MEAL CLAIM REIMBURSEMENT VERIFICATION FORM—ALL SCHOOLS

OMB Number: 0584-0530

Expiration Date: XX/XX/XXXX

Fourth Access, Participation, Eligibility and Certification Study Series (APEC IV)

D3. SFA MEAL CLAIM REIMBURSEMENT VERIFICATION FORM—ALL SCHOOLS

SFA Name: _______________________________________________________

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

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

MONTH DAY YEAR

___________________________________________________________________________________________________________

Target Month = October, 2023

1. SFA CONSOLIDATED MEAL CLAIM – FOR ALL SCHOOLS CONSOLIDATED

A1. NON CEP SCHOOLS

BREAKFASTS	LUNCHES
Free: | |,| | | |,| | | | Reduced: | |,| | | |,| | | | Paid: | |,| | | |,| | | | Total: | |,| | | |,| | | | Number of Schools: | | |,| | | |	Free: | |,| | | |,| | | | Reduced: | |,| | | |,| | | | Paid: | |,| | | |,| | | | Total: | |,| | | |,| | | | Number of Schools: | | |,| | | |

 Check here if this includes both CEP and Non-CEP schools because the SFA doesn’t have consolidated total by school type.

A2. CEP SCHOOLS (ENTER “TOTAL” MEALS ONLY). LEAVE BLANK OF A1 includes both CEP and NON CEP Schools.

BREAKFASTS	LUNCHES
Total: | |,| | | |,| | | | Number of Schools: | | |,| | | |	Total: | |,| | | |,| | | | Number of Schools: | | |,| | | |

COMPLETE ONE FORM PER SCHOOL

SFA Name:

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

School Name:

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

Sampled School: YES OR NO

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

MM DD YYYY

Target Month = October, 2023

Number of Breakfast Serving Days: | | |

Number of Lunch Serving Days: | | |

(If breakfast or lunch was not served, enter “0”)

A: BREAKFAST MEAL CLAIMS FOR CEP SCHOOLS, ENTER “TOTAL” MEALS ONLY.
REPORTED TO SFA BY SCHOOL				REPORTED TO STATE AGENCY BY SFA
Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |				Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |
COMPLETE FOR PROVISION SCHOOL IN NON-BASE YEAR ENTER THE CLAIMING PERCENTAGES USED:				BASE YEAR PERIOD USED:
FREE | | | |.| | | | % OR | |.| | | |	REDUCED | | | |.| | | | % OR | |.| | | |	PAID | | | |.| | | | % OR | |.| | | |		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH USED:
COMPLETE FOR CEP SCHOOL ENTER THE CLAIMING PERCENTAGES USED (FOR BREAKFAST AND/OR LUNCH):
			FREE | | | |.| | | | % OR | |.| | | |		PAID | | | |.| | | | % OR | |.| | | |

B: LUNCH MEAL CLAIMS FOR CEP SCHOOLS, “TOTAL” MEALS ONLY.”
REPORTED TO SFA BY SCHOOL			REPORTED TO STATE AGENCY BY SFA
Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |			Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |
COMPLETE FOR PROVISION SCHOOL IN NON-BASE YEAR ENTER THE CLAIMING PERCENTAGES USED:			BASE YEAR PERIOD USED:
FREE | | | |.| | | | % OR | |.| | | |	REDUCED | | | |.| | | | % OR | |.| | | |	PAID | | | |.| | | | % OR | |.| | | |	YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH USED:

REPEAT FOR EACH SCHOOL.

C. COMMENTS

Record any notes in the records, or reported to you by SFA staff, indicating that the SFA corrected or adjusted the school breakfast or lunch meal counts. Also, include any notes that may be related to any potential discrepancies between school meal counts (what the school reported to the SFA) and SFA meal claims (what the SFA reported to the State).

D. QC REVIEW (required)

 Check here to confirm that a QC review of the data entered was conducted, and all data entered is complete and accurate.

This information is being collected to provide the Food and Nutrition Service with key information on the annual error rates and improper payments for the school meal programs. This is a voluntary collection and FNS will use the information to examine school meal error rates and inform future APEC studies. This collection requests personally identifiable information under the Privacy Act of 1974. 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 to complete this information collection is estimated to average 1.0 hours (60 minutes) per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22306 ATTN: PRA (0584-0530). Do not return the completed form to this address.

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