Administration and Forms for CACFP

CACFP Forms

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Form Name Form Number Form Download Form Download (Alternative Format) Instructions Download Program Name
2023 Income Eligibility Guidelines for Determining Free and Reduced Price Benefits H1625-A Download File CACFP - Adult Day Care
2024 Income Eligibility Guidelines for Determining Free and Reduced-Price Benefits H1625-A Download File CACFP - Adult Day Care
Addendum - Option to Renew IFB and Contract for Purchased Meals ADC IFB - RENEW ADC Download File Download File CACFP - Adult Day Care
Amendment 1 to Permanent Agreement Between Sponsoring Organization and Adult Day Care Site AMEND 1 Download File Download File CACFP - Adult Day Care
Annual Audit AUDIT Download File Download File CACFP - Adult Day Care
Application for Texas Identification Number AP-152 Download File CACFP - Adult Day Care
CACFP - Centers Claim for Reimbursement - Site Level Download File Download File Download File CACFP - Adult Day Care
CACFP Meal Benefit Income Eligibility Form (Adult Care) Download File Download File CACFP - Adult Day Care
CACFP Meal Benefit Income Eligibility Form (Adult Care) in Spanish Download File Download File CACFP - Adult Day Care
CACFP Meal Benefit Income Eligibility Form Letter to Households (Adult Day Care) Download File CACFP - Adult Day Care
CACFP Meal Benefit Income Eligibility Form Letter to Households (Adult Day Care) in Spanish Download File CACFP - Adult Day Care
CACFP Medical Statement Form Download File Download File CACFP - Adult Day Care
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts H2048 Download File Download File CACFP - Adult Day Care
Certification Regarding Federal Lobbying H2049 Download File Download File CACFP - Adult Day Care
Child Nutrition Programs Waiver Request Download File Download File CACFP - Adult Day Care
Claim for Reimbursement Worksheet - Meals H4502 Download File Download File Download File CACFP - Adult Day Care
Contracting Entity Request for Waiver of 15% Limit for Allowable Administrative Costs Download File CACFP - Adult Day Care
Daily Meal Count and Attendance Record (Centers and Emergency Shelters) H1535 Download File Download File CACFP - Adult Day Care
Daily Meal Production Record - Adult Day Care H1654 Download File Download File CACFP - Adult Day Care
Direct Deposit Authorization 74-176 Download File CACFP - Adult Day Care
Documentation of Meals Claimed H1540 Download File Download File CACFP - Adult Day Care
F&N Complaint Form - English Download File Download File CACFP - Adult Day Care
F&N Complaint Form - Spanish Download File Download File CACFP - Adult Day Care
Food Service Management Company/Vendor Monitor Review H1529 Download File Download File Download File CACFP - Adult Day Care
Free and Reduced Price Meal Policy Statement (For Contractors that Charge Separately for Meals) H1667 Download File Download File CACFP - Adult Day Care
Gender Separation Exception Request Form Download File CACFP - Adult Day Care
Governing Body Awareness GBA Download File Download File CACFP - Adult Day Care
Invitation for Bid and Contract for Purchased Meals IFB - ADC Download File Download File CACFP - Adult Day Care
Letter of Determination - Pricing Programs H1663 Download File Download File CACFP - Adult Day Care
Payee Change Request 74-157 Download File CACFP - Adult Day Care
Performance Bond BOND Download File CACFP - Adult Day Care
Permanent Agreement Between Sponsoring Organization and Adult Day Care Site Download File Download File Download File CACFP - Adult Day Care
Permanent Agreement Contracting Entity Specific Amendment - Name Download File CACFP - Adult Day Care
Permanent Agreement Contracting Entity Specific Amendment - Programs Download File CACFP - Adult Day Care
Pre-Approval Visit H1602-P Download File Download File CACFP - Adult Day Care
Pre-Award Civil Rights Compliance Review Download File Download File CACFP - Adult Day Care
Racial/Ethnic Participant Data Collection Prototype Download File Download File CACFP - Adult Day Care
Record of Leftover/Recycled Food H1568 Download File Download File CACFP - Adult Day Care
Review H1602 Download File Download File CACFP - Adult Day Care
Sponsoring Organization Disbursement Record H4503 Download File Download File Download File CACFP - Adult Day Care
Texas Department of Agriculture Food and Nutrition Division Permanent Agreement Download File CACFP - Adult Day Care
Milk Flexibility for Emergency Conditions Notification Form Download File CACFP - Adult Day Care
Good Cause Transfer Request Form Download File Download File CACFP - Adult Day Care
Micro-Purchase Log Download File Download File CACFP - Adult Day Care
2023 - 2024 School Data for Area Eligibility SCHOOL DATA Download File CACFP - At-Risk Afterschool
2022 - 2023 School Data for Area Eligibility SCHOOL DATA Download File CACFP - At-Risk Afterschool
Addendum - Option to Renew IFB and Contract for Purchased Meals CCC & DCH IFB - RENEW CCC & DCH Download File Download File CACFP - At-Risk Afterschool
Addendum - Option to Renew IFB and Contract for Purchased Meals SFSP & At-Risk IFB - RENEW SFSP & AT-RISK Download File Download File CACFP - At-Risk Afterschool
Amendment 1 to Permanent Agreement Between Sponsoring Organization and Child Care Site AMEND 1 Download File Download File CACFP - At-Risk Afterschool
Amendment 2 to Permanent Agreement Between Sponsoring Organization and Child Care Site AMEND 2 Download File Download File CACFP - At-Risk Afterschool
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Assistance available in English and Spanish. Please call 877-TEX-MEAL (877-839-6325) for help. Additional translations services available as well.

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.
 

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.
 

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

1. Mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410; or
2. Fax: (833) 256-1665 or (202) 690-7442; or
This institution is an equal opportunity provider.
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