FNS-843 Report of Disqualification from Participation: Instituti

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Midwest

2

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0

0

Northeast

2

0

0

0

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0

Western

0

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lntiroduction

This infonnation is being collected to assis ,e Food a d Nutrition Service in maintaining, the National Disqualified List o institutions, day care home
providers, and individuals that have been terminated or 0U1erwise disqualified from participation in he Child and Adult Care Food Program (CACFP). This
is a mandatory collectiion un - er Section 243(c) of Public law 106-224, the Agricultural Risk Protection Act of 2000, which amended section (42 U.S.C.
1766(d)(5)(E)0) a d (iil) of the Richard B. Russe'II National Sc ool unch Act a d der 7 CFR 226.6(c)(7)(i). FNS uses the information to adminis!e the
program and ensures that i Is ava·lab:le to tale agencies for their use in revie"Mngi applicatio� o participate and to sponsoring1 organizations to ensure
that hey do not employ as principals any persons who are d'squalified from the program. This collectJion requests personally identifiable ,information which
will be kept private to ttie extent provided by law under the Privacy Act of 1974 and SORN USDA/FNS-H lnfo�mation on Persons !Identified as
Responsible or Serious Deficiencies, Proposed for Disquialification, or Disqualified to Participate as Principals rnr Family Day Care Home Operator.; in �he
CACFP
Warning: The intended use of tlhe National Disqualified List is only to verify that al who apply to operate the Child and Adult Care Food
Program qualify to participate. Any olher use of the N.ational Disqualified List is strictly prohibited. By entering ·U,is site, you are agr,eeing to use
the site for only ttiis purpose.

o

B Number: 05840584
Expirati ion Date: 7/31XXXX
According to the Paperwork ReductionAot of 1995, a11 agency may no conduct or sponsor, and a person is not required to respond to, a collection of
infomi:ation unless ·t displays a vallid 0MB control number. The valid 0MB control number for this informatio , collection is 0584-0584. The time required to
comp e!e �his infoITTmation oollecti:on is estimated to average 30 minutes (0.50 hours) per response, ind ding tlile time for reviewing instructions, searching
e ·sting data sources, gathering and maintai ing the data needed, and completing and eview·ng the collection of informaron. Send comments regarding
this burden estimate or any other aspect of this collection of informat,ion, including suggestions for reducing U1,is burden, to:

ATTN: PRA (0584-0584)
US. Department of Agriculture, Food and Nutrition Service, Office of Policy Support
Braddock Metro Center II
1320 Braddock Place
Alexandria, VA 22314
Do not return the completed form to this address.

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A-1 FNS-843 Report of Disqualification from Participation –
Institution and Responsible Principals/Individuals