State and Local Burden - SA, SFA/LEA

Attachment N.12. Non-reimbursable Meal Allocation Form

This information is being collected from State agencies, school food authorities, schools. This is a revision of
a currently approved information collection. The Richard B. Russell National School Lunch Act (NSLA) 42
U.S.C. § 1758, as amended, authorizes the National School Lunch Program (NSLP). This information is
required to administer and operate this program in accordance with the NSLA. Under the Privacy Act of
1974, any personally identifying information obtained will be kept private to the extent of the law.
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 0584-0006. The time required to complete this
information collection is estimated to average 47.5 hours of reporting burden per response. The burden
consists of the time it takes for the State agency to conduct the off-site portion of the review which includes
scheduling of the review and the completion of the Off-site Assessment, Resource Management Risk
Indicator, and Site Selection Tools. 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 Services, Office of Policy Support, 3101 Park Center Drive, Room 1014,
Alexandria, VA 22302, ATTN: PRA (0584-0006). Do not return the completed form to this address.

OMB #0584-0006
Expiration Date
xx/xx/20xx

NONREIMBURSABLE MEAL ALLOCATION FORM

SFA:

SCHOOL:

Check one:

FISCAL YEAR:

Day of Review [ ]
Review Period [ ]
Periods Other than the Review Period [ ] _____________________

Check all that apply:

Ineligible Meals [ ]

NSLP [ ]

Missing Meal Component/Food Item [ ]

SBP [ ]

Incomplete Meals [ ]

ASP [ ]

A.
Meals
Claimed by
Category

B.
Total
Meals
Claimed

C.
Ratio of
Total by
Category
(A ÷ B)

D.
Total Meals
in Error

E.
Meals Claimed
in
Error by
Category
(C x D)

Free

Reduced
___________

____________

Paid
TOTAL

NONREIMBURSABLE MEAL ALLOCATION FORM Last updated School Year 2017-2018

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INSTRUCTIONS
NONREIMBURSABLE MEAL ALLOCATION
Use this form to assign ineligible meals, meals missing meal components, and incomplete meals subject
to fiscal action for periods other than the review period and day of review at reviewed schools and for all
claim periods in non-reviewed schools when meal disallowances by category cannot be obtained.
Additionally, use this form to assign ineligible snacks for the day of review, review period, periods other
than the review period, and for all claim periods in non-reviewed schools when disallowances by category
cannot be obtained.
Complete a separate form for each Program. If the errors affect two fiscal years, separate forms for each
fiscal year must be completed.
A.

Enter the free, reduced-price and paid meals from the claim for the review period. For the NSLP,
enter the number of lunches claimed, for the SBP enter the number of breakfasts claimed, for the
ASP, enter the number of snacks claimed. For other claim periods at reviewed schools or all
claim periods at non-reviewed schools, record the number of meals, by category, claimed by the
SFA for the school.

B.

Total the number of meals claimed by category and record in column B

C.

To calculate the free and reduced price ratios, divide column A by column B, carry to four decimal
places and round to three places beyond the decimal. Record the results by category in column
C. Determine the paid participation rate by subtracting the sum of Column C, free plus reduced,
from 1.000.

D.

Record the number of meals which must be allocated.

E.

Multiply column C by column D and record the results by category. The total number of meals in
column E cannot exceed the number of lunches in column D. Adjust the entry for Paid if the total
number of lunches in column E is different from column D. This adjustment is due to the effects
of rounding.

Transfer the disallowed meals to the School Data and Meal Pattern Error Form, S-1 (Non-reimbursable
meals) and/ or Page 3 (Afterschool Snacks) as applicable.

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