Worksheet FNS 10 OMB# 0002

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U.S. DEPARTMENT OF AGRICULTURE
FOOD AND NUTRITION SERVICE

4. TYPE OF SUBMISSION
("X" ONE)

1. STATE

REPORT OF SCHOOL
2. CALENDAR YEAR

PROGRAM OPERATIONS

A.

30 - DAY

B.

60 - DAY

C.

90 - DAY

D.

FOR FNS USE ONLY
CAL. YEAR

90 - DAY

3. MONTH

TYP

STATE CODE

REVISION NO.

STATE AGENCY: Submit report according to the instructions 30 and 90 days
following the month being reported.
Send original to the Regional Administrator, Food & Nutrition Service.

MONTH

(1 = 1st rev., 2 = 2nd , etc.)

E.

CLOSEOUT

F.

OTHER - (Describe)

PART A - (Complete Monthly)
ITEM

NUMBER OF MEALS AND HALF-PINTS SERVED

(Include Residential Child Care Institutions
(RCCIs) In Items 5 thru 8.)
5. NATIONAL SCHOOL LUNCH
PROGRAM
a. Total lunches served in the
NSLP
(Include all lunches reported in
5b1 and 5b2)

ACTUAL

b1. Lunches served in school
food authorities that qualify
the state for additional
payment

ACTUAL

PAID

FREE

REDUCED PRICE

TOTAL

AVERAGE DAILY MEALS

(A)

(B)

(C)

(D)

(E)

ESTIMATED
TOTAL

ESTIMATED
TOTAL

b2. Lunches served in school food ACTUAL
authorities certified for
ESTIMATED
performance based
reimbursement
TOTAL
c. Total afterschool snacks served
in all approved schools and
sites. (Include in Col. B, all free
snacks reported in item 5d,
below)
d. Total afterschool snacks
served in area eligible
schools and sites

ACTUAL
ESTIMATED
TOTAL
ACTUAL
ESTIMATED
TOTAL

6. SCHOOL BREAKFAST
PROGRAM

ACTUAL

(Include schools with severe
need)

TOTAL

7. SCHOOL BREAKFAST
PROGRAM

ESTIMATED

ACTUAL
ESTIMATED

(Severe need only)

TOTAL

8. COMMODITY SCHOOLS

ACTUAL
ESTIMATED

(Lunches only)

TOTAL

9. SPECIAL MILK PROGRAM

ACTUAL

a. Schools
(Include Residential Child Care
Institutions)

ESTIMATED
TOTAL
ACTUAL

b. Nonresidential Child Care
Institutions

ESTIMATED
TOTAL
ACTUAL

c. Summer camps

ESTIMATED
TOTAL

FORM FNS-10 (07-23) Previous Editions Obsolete

Electronic Form Version Designed in Adobe 10.0 Version

NO FURTHER MONIES OR OTHER BENEFITS MAY BE PAID OUT UNDER THESE PROGRAMS
UNLESS THIS REPORT IS COMPLETED AND FILED AS REQUESTED BY EXISTING REGULATIONS
(7 C.F.R. 210, 215, & 220)

PART B - (Complete Once A Year As Specified)
ITEM

FOR
FNS
USE
ONLY

NUMBER OF MEALS SERVED
PAID

FREE

REDUCED PRICE

TOTAL

AVERAGE DAILY MEALS

(A)

(B)

(C)

(D)

(E)

10. REPORT NO. OF MEALS SERVED
IN PRIVATE SCHOOLS ONLY
a. National School Lunch Program
b. Afterschool snacks (include area
eligible snacks reported in 10c.)
c. Afterschool snacks served in area
eligible schools & sites.
d. School Breakfast Program
(include severe need)
e. Severe Need School Breakfast
Program
11. REPORT NO. OF MEALS SERVED
IN RCCI'S ONLY
a. National School Lunch Program
b. NSLP - Snacks

OCTOBER

c. School Breakfast Program
(include severe need)
d. Severe Need School Breakfast
Program

OPERATING A PROGRAM THIS MONTH

NATIONAL
SCHOOL
LUNCH
(F)

12a. Number of Public Schools
b. Membership (Enrollment)
13a. Number of Private Schools
b. Membership (Enrollment)
14a. Number of Residential Child Care Institutions
b. Membership (Enrollment)
15. NUMBER OF CHILDREN APPROVED FOR:
a. Free Lunches - - TOTAL
b. Reduced-price Lunches - - TOTAL

JULY

16. NUMBER OF NONRESIDENTIAL
CHILD CARE INSTITUTIONS
17. NUMBER OF SUMMER CAMPS OPERATING
A PROGRAM FOR THE MONTH OF JULY
ONLY

NSLP SNACKS NSLP SNACKS
SCHOOL
SCHOOL
COMMODITY
(All schs &
BREAKFAST BREAKFAST
(Area Elig.
sites; incl.
Only)
(Inc. Sev. Nd) (Sev. Nd Only)
Col. H)
(G)

(H)

(I)

(J)

(K)

SPECIAL
MILK
(L)

PART C – Seamless Summer Option (SSO) Reporting (Complete Monthly)
ITEM

NUMBER OF MEALS SERVED

(Include Residential Child Care Institutions
(RCCIs) In Items 5 thru 7.)
18. SSO LUNCHES
a. Total congregate lunches

FREE (A)

TOTAL (B)

AVERAGE DAILY MEALS (C)

ACTUAL
ESTIMATED
TOTAL

b. Total non-congregate lunches

ACTUAL
ESTIMATED
TOTAL

19. SSO SNACKS
a. Total congregate snacks

ACTUAL
ESTIMATED
TOTAL

b. Total non-congregate snacks

ACTUAL
ESTIMATED
TOTAL

20. SSO BREAKFASTS
a. Total congregate breakfasts

ACTUAL
ESTIMATED
TOTAL

b. Total non-congregate
breakfasts

ACTUAL
ESTIMATED
TOTAL

PART D – SSO MONTHLY PARTICIPATION – 90 DAY REPORT ONLY

OPERATING A PROGRAM THIS MONTH

Congregate

Non-Congregate

(A)

(B)

21. Number of Public Schools
22. Number of Private Schools
23. Number of Residential Child Care Institutions
24. Number of operating days

25. REMARKS



I CERTIFY THAT THIS REPORT IS TRUE AND CORRECT TO THE BEST
OF MY KNOWLEDGE AND BELIEF

20. SIGNATURE

21. TITLE

19. AGENCY

22. DATE SIGNED

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