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1996-083NOTE. SUPPLEMENTAL AGREEMENT SUMBITTED BY PARKS DEPARTMENT ATTACHED TO ORIGINAL.Changed pages are noted ORDINANCE NO q~-O~ AN ORDINANCE OF THE CITY OF DENTON, TEXAS, AUTHORIZING THE ACTING CITY MANAGER TO EXECUTE A CONTRACT WITH THE DENTON INDEPENDENT SCHOOL DISTRICT AND ALL ADDITIONAL DOCUMENTS AND AGREEMENTS, AS REQUIRED, TO OBTAIN FUNDING FOR THE 1996 SUMMER FOOD SERVICE PROGRAM, AUTHORIZING THE EXPENDITURE OF FUNDS TO ADMINISTER THE PROGRAM, AND PROVIDING AN EFFECTIVE DATE WHEREAS, the Cmty of Denton, Texas will submit an appllcatmon for fundmng under the Natmonal School Lunch Act, to the Texas De- partment of Human Servmces for the purpose of makmng meals avaml- able to elmgmble chmldren at the Cmty's Summer Actmon Smte pro- grams, and WHEREAS, pursuant to the grant, mf received, the City wmll con- tract wmth the Denton Independent School Dmstrlct to provmde the meals at the varmous smtes, NOW, THEREFORE, THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS ~ That the Acting Cmty Manager ms hereby authormzed to execute, on behalf of the Cmty, an applmcatmon for fundmng under the Natmonal School Lunch Act, and if funded, the Summer Food Ser- vmce Program Agreement wmth the Texas Department of Human Servmces, a copy of whmch ms attached hereto and mncorporated by reference heremn, along wmth any other documents necessary to obtamn such funding ~ II That the Actmng Cmty Manager ms hereby authormzed to execute a contract with the Denton Independent School Dmstrmct, substantmally mn the form of the contract whmch ms attached to and made a part of this ordznance for all purposes, to provmde meals for ellgmble zndmvmduals at the varmous sztes, and such certlfmcatmons as are necessary to carry out the 1996 Food Servmce Program, and to handle all fmscal and admznmstratmve matters relating to the appllcatmon and the program SECTION III That the expendmture of funds necessary to admmnmster the 1996 Summer Food Service Program ms hereby authormzed ~ That thms ordznance shall become effectIve immed- iately upon mrs passage and approval PASSED AND APPROVED thms the ~-~ day of ~ , 1996 BOB CASTLEBERRY, MAYO~ ~ / ATTEST JENNIFER WALTERS, CITY SECRETARY APPROVED AS TO LEGAL FORM HERBERT L PROUTY, CITY ATTORNEY Page 2 SUMMER POOD SERVICE PROGRAM FO~ DHS ~I'AFF ONLY APPLICATION FOR PARTICIPATION ~x No E~ ;~e FY NOTE Give I~ mu~h InJoi~MJm~ IS po~dlde Attach ilddlife?sl ..sheets If .n?71d, [] Bmak~ [] A.M Supp [] Lunch i~eiseMentifyelol~sttishnlefltw#hthenameoftheoontraotlngorgar"za"o ~"~PM Supp ~-'}Supper ["-~All SECTION i-SPONSOR INFORMATION T.;.~..,. No CtC7 of Denton 17560005]46015 $17 ) .566-8125 ('817) 566-8125 Am~m~ (Slmet m* P O Box. City, Siam, ZiP) 321 E McKinney Denton, Texas 76201 Teresa Milam Leisure Services Manager A Conlmctor Classlfloatiofl (Che~ all that apply) ~ Ao~dmlo Year ~tlonal Una of ~m~nt~ff~ ~ ~t al ~ D ~1Y~ 8~ P~mm ~ Y~ S~ P~mm ~ ~ s~es ~e ~ d~r~y W ~ ~ R~onm~ldent~l Co~nuoua ~le~r ~ ~1 F~ A~ U ~mMr ~mp ~ ~l Year ~ PHW Non.fit B Is ~ur ~mm a ~.mund ~? ~Yes ~ No C T~ ~ ~r ~ ~ ~ ~r ~ ~ ~l~ ,~ ~ S~m Tm.u~? ~ N/A ~ Yes ~ No D ~ ~ ~ ~ ~ ~g ~ar-~nd .e~ m me ~mun~ ~at ~ m ~ s~ W ~y. ~ ~ · e ~r F~ ~ Pq~ If ~, ~ ~ ~ f~ ~ ~ ~ M~ C~ ~ F~ m o~ ~M de~ I ~n~t ~m~ d ~mn ~ m ~mm E 1 ~8 ~ ~ ~ 81~,~ ~ ~ ~ f~ funds ye~? ~Y~ ~ No ~, ~di~ ~ ~ K ~li ~ ~d ~ must submit a ~mpl~ Fo~ 1~, S~I N~riilon ~mms - Sidle A~ ~ ~m ) SECTION II-~UDOET A E~mate all SFSP costs wi~ich will be claimed for reimbursement for the ~ro~ram year Adm~nistrative Labor Program Labor 4,22_5 IManagement, Monitor, Clencol) 3, ! ! .5 Fringe Befl~ 422 Fringe Benefits 311 , Food 26,699 Rental of Offlco Spaco Non-food SuplNles I, 500 U~ilitMs ~ Offl~ Supplies 200 Rent Offl~ Building Malntenanco Equipment Use Fee Equipment Use Fee RentaJ of Equipment 2,500 Audit Fee,, Tmnspor~on 28 445 Legal Fees TranN~orte~ion ~/ ,8 Mobile Phone 300 TOTAL 1 35,791 TOTAL 2 3,926 B Indicate projeoted ~me to ~he rood service from all ~me$ other b"mn iFSP relmtmmement Idest~y exactly the costs mis Income will cover (Do not Include state or federal luncl$ ) $ SECTION #I-MANAGEMENT PLAN A, List edmlnlstmltve level personnel who wdl be responalb4e for management and man#oring of b~e SFSP (Do not inctu,~e site supervisors, cooks, j~mltms or o~her personnel involved m on-site food service ) Director 1 Conducts training session, monitor sites, prepares reports, coordinates food ~ervices Coordinator 1 Assists Director with duties E Are children charged saparataly for meals? If yes, see Form 'i508, Attachment B C Do you want to receive advance payments? I lyes ~ No If yes, 1 For Operational Costs? ['-'~Yee [] No 2 For Adm~mStrative Costs? I Iyee No D If meal service s salf.preparetion, do you want to receive commodities? L_JYes IxI No If yea, Form 1606, A~ppl/~at/on and Agreement for Commodities, must be comp eted SECTION IV-PROGRAM OPERATION May 28, 1996 August 9, 1996 A 1 Beginmng and Endlng Dates of Meal Serv=e From through 9 2 Numborof sties B List d~te~ ane topics ol ~-=r, [r~un,~ 5/23/96 Site supervisor and monitor training on S F S P guidelines and Civil Rights training C Is the organizaben planning to contract w~th a food service management company []Ye~ [] No for the preparation of unitized meals? If ~/es, and the ~,,;;&~ will -~,-- -~-~,~ $10,000, attach a cow of the invitation to bid Also ~w, ~te ~ Bid i$ bk] exp~ to t)e S1000(30 or mo~e? [~] Ye~ [~No t/~lt yes g~ve p~ace ot bgl u~m,..a' Also, atth~ a cow of an Il-day-cycle menu mctud~ng ail spec~f,c menus to be used D Is the organization contracting with a year-rounri food sen, ice management company? [Yea [] No If yes, submit a copy of your procurement procedures, bid, contract, and ell amendments E Attach a copy of the letter which has been (or wdl be) sent by the organization to the Health Department notifying them of ~ntant to operate a Food Sen,~ce Program at the site(s) Indicated on the attached Site Information sheet (Form 1507) SECTION V-ASSURANCES A Free Meal Policy Statement 1 The contrachng orgamzation assures the Texas Department of Human Senncas (DHS) that all children at the s~a deecdbad on the Site(s) Information Sheets for the Summer Food Sewice Program, will be oIfered the same meals with no physical segregation of, or other discrimination agmnst, any child because of race, color, dmabillty, age, sex, national origin, religion, or political betiefs No separate charge will be made for any meal except in accordance with attachment B of this abplicetion 2 TI~ contracting organization assures DHS that, if it is sponsoring camps or other enroilmant programs · The centra~ng organization has or will obtain family size and Income data about all children whose meals will be tape. ad as free or reducad-pnce,land · The children claimed as free or reduced-price meet the ~urrant famdy sma and ~nceme standards set by the Un,tad States Department of Agriculture, DHS Form 4504, Standards for De~ernl/ning Free and Reduced. Price EI/g/b#/ty FMm 1606 3 If the contracting organization is sponsonng a camp or other enrollment program that charges separately for meals, the contractln@ organization has read Attachment B to the application, "Additional Assurances for Camps and Other Enrollment Programs that Charge Separately for Meals", and assures DHS that all redu~raments have I~ean or will be met B Public Release I The ;oNrecting organization wdi make efforts to ensure that the tocal news medta will make a public announcement of the program and will Supply them with a news release If the contracting organization ~s sponsonng a camp or other enrollment program, this release must contain, at a m~nlmum, a hst of all approved sites, a list of the current standards for determming free and recuded price eligibility, and the following statement City of Denton "The (Name of the contmot~ or~anlzatio~) announces the epanoorehlp of the Summer Food Service Program Inoome eligibility will be baaed on family size and income using the Standards for Determining Free end Reduced-Price Eligibility, provided by the United States Department of Agrloulture Meats will be provided at the site(s) listed People who are eligible to participate In the program must not be dl~dminated egainlt beoouae of ra~e, color, national origin, aox, age, disability, religion, or polltloel belief Anyone who believes that they h~ve I~en dta~rimln~led against should write Immediately to Director, CIvil Rights Division, MC W-106, Texas Department of Human Services, P O Box 149030, Auedn, Texas 78714,9030 or the Secretary of Agriculture, Washington, D C 20250 NOTE Diandmlnation comptalnta baa~J on religion or polltloal beliefs must be referred only to the Direotor, Civil Rights Division, Texas Department of Human ~e~vl~e~." For all other programs the announcement must contain, at a minimum, a list of all approved sites and the following statement: Cit~ of Denton "The ~Nmne~ the oontrac~n~ organlza~nl announces the pponeorahlp of the Summer Food Service Program Meals will be provided at the site(a) listed People who are eligible to participate In the program must not be dl~rlmlnoted against beoause of race, color, national origin, sex, age, disability, religion, or p~lltleal belief. Anyone who believes lhat they have been dlasrlmlnatad against 8hauld write Immedtataiy to Dlrastor, Civil Righta Division, MC W-106, Texas Department of Human Services, P O Sox 149030, Austin, Texas 78714,9030 or the Secretary of Agrloulture, Washington, D C 20250 NOTE Dicerlmlnafloo oomplainta baaed on religion or political beliefs must be referred on/y to the Dlreotor, Civil Rights Division, Texas Department of Human Servloes" This public release was or wdl be pubhshed m the tollowin~l news media outfl)t(s} WE OF MED~A OUT, ET t OATS OF RELEASE NAME OF MEOIA OUTLET DATE O~ RELEA~ Denton Record Chronicle 5/1/96 TWU Student Paper 5/1/96 Dallas Morning News 5 / 1/96 KDNT Radio 5 / 1/96 UNT Daily 5/1/96 KNTU Radio 5/1/96 3 Attach a copy of the contacting organization's public release statement as submitted to the news media and any ob'mr materials used to publicize the program's availability and nondmc~m~natlon requirements SECTION VI- CER~FICATION (see Form 1506, Attachment C) I certify that Ihs Information on this application Is true and correct to the beet of my knowledge I certify that reimbursement will be oialmed only~.qr..~pproved meals served to eligible children during the hours they are in attendance at approved sites I know that dellharata~Mr-erap~entatlon or withholding of information may result in prosecution under appll~lble state and federal statutes Nsme(~Ne~lMMPI~IgRick Svehla ~ Acting City Manager I FOR DHS USE ONLY r--]APPROVED ['"'~DENIED If denied, rea~n CITY of DENTON, TEXAS MUNICIPAL BUILDING · 215 E McKINNEY · DENTON, TEXAS 76201 (817) 566-8200 · DFW METRO 434-2529 February 21, 1996 Ms Laurie Cailahan, Registered Samtanan Environmental Health Department 300 Woodrow Denton, Texas 76205 Dear Ms Callahan, The Denton Parks and Recreation Department is applying to the Texas Department of Human Servmes for a grant to provide the Summer Food Service Program to the cluldren of Denton This program vail prowde lunch for cluldren ages 1 - 18 years of age The food preparation vail be contracted with the Denton Independent School Diana We will be serving sack lunches from igloos at the sites hsted below Tlus is a request that your department respect the locations of food service Time of Site/Address Dates Lunch Service Clwc Center Park 5/28/96 - 8/9/96 12 00pm- 1 00pm 321 E McKmney Phoemx Park 5/28/96 - 8/9/96 12 00pm- 1 00pm Wood Street Owsley Neighborhood 5/28/96 - 8/9/96 12 00pm-1 00pm Stella Street Dema Park 5/28/96 - 8/9/96 12 00pm- 1 00pm 1001 Parvm "Dedtcated to Quahty Servtce" TWIJ Clubhouse 5/28/96 - 8/9/96 12 00pm-1 00pm Mary Hufford Court Village East Apts 5/28/96 - 8/9/96 12 00pm-1 00pm 1700 Village East Houston Elem School 6/3/96 - 6/28/96 I l 45am-12 45pm 3100 Teasley Rayzor Elem School 6/3/96 - 6/28/96 11 30am-12 30pm 1400 Malone MLK Recreation Center 5/28/96 - 8/9/96 12 00pm- 1 00pm 1300 Wilson If you have any questions I may be reached at 566-8125 Brenda Burton Cluldren's Programs Supervisor Summer Food Serv~c~e Program Sack Lunches Menus Eleven Day Cycle Tuesday - May 28 Peanut Butter/Jelly Sandwich 2 oz Peanut Butter, 1 T Jelly, 2 shoes Bread Carrot St~cks 1/4 cup Banana 1/2 cup Lowfat Ivhlk 1/2 pint Wednesday - May 29 Bologna/Cheese Sandwmh 1 1/2 oz Bologna, 1/2 oz Cheese 2 shoes Bread Carrot Corns 1/4 cup lVhxed Frmt 1/2 cup Potato Chips Lowfat l~lk 1/2 prat Thursday - May 30 Tuna Salad Sandwich 2 oz Tuna 2 shces Bread Pinkie Spears 1/4 cup Orange Jmce 6 oz Lowfat Milk 1/2 prat Friday - May 31 Ham/Cheese Sandwich 1 1/2 oz Ham, 1/2 oz Cheese 2 shees Bread Whole Pinkie 1/4 cup Frmt Cup 1/2 cup Cookie Lowfat lVhlk 1/2 pmt Monday - June 3 Deh Sandwmh 2 oz Meat 2 shces Bread P~ckle/Carrot 1/4 cup M~xed Frmt 1/2 cup Lowfat IVhlk 1/2 pmt Tuesday - June 4 Peanut Butter/Jelly Sandwich 2 oz Peanut Butter, 1 T Jelly 2 shces Bread Carrot St~cks 1/4 cup Apple 1/2 cup Lowfat IVhlk 1/2 prat Wednesday - June 5 Deh Sandwich 2 oz Meat 2 shces Bread Pinkie/Carrot 1/4 cup Apple 1/2 cup Lowfat IVhlk 1/2 prat Thursday - June 6 Tuna Salad Sandwich 2 oz Tuna 2 shces Bread Pickle Spears 1/4 cup Orange Juice 6 oz Lowfat Malk 1/2 prat Friday - June 7 Ham/Cheese Sandwich 1 1/2 oz Ham, 1/2 oz cheese 2 shces Bread Whole Pickle 1/4 cup Fruit Cup 1/2 cup Coolae Lowfat IVhlk 1/2 ptnt Monday - June 10 Bologna/Cheese Sandunch 1 1/2 oz Bologna, 1/2 oz Cheese 2 shces Bread Carrot Corns 1/4 cup 1Vhxed Fruit 1/2 cup Potato Clups Lowfat Milk 1/2 prat Tuesday - June 11 Deh Sandwich 2 oz Meat 2 shces Bread P~ckle/Carrot 1/4 cup Banana 1/2 cup Lowfat Milk 1/2 prat Certification That All Required Pre-operational Site Visits Have Been Conducted At All Proposed S~tes Name Of Person Name Of Sate V~sated Date Of V~s~t Who V~sated Sate Cavm Center Park February 8, 1996 Brenda Burton Phoemx Park February 8, 1996 Brenda Burton Owsley Neighborhood February 8, 1996 Brenda Burton Dema Park February 8, 1996 Brenda Burton MLK Recreatmn Center February 8, 1996 Brenda Burton TWU Clubhouse February 8, 1996 Brenda Burton Vdlage East Apts February 8, 1996 Brenda Burton Houston Elementary February 8, 1996 Brenda Burton School Rayzor Elementary February 8, 1996 Brenda Burton School S~gnature of Authorized Representattve Date CITY of DENTON, TEXAS MUNICIPAL BUILDING, 215 £ McKINNEY , DENTON, TEXAS 76201 (817) 566 6200, DFW METRO 434 2529 MEMORANDUM To Sohd Waste Department From Brenda Burton, Cluldren's Programs Superxqsor Parks and Recreation Department Date February 9, 1996 Subject Summer Food Serwce Program The Summer Food Serwce Program, wl~ch provides sack lunches for cluldren throughout the summer, ~s being sponsored by the Denton Parks and Recreation Department I would hke to make you aware that addmonal trash wdl be placed m dumpsters on Monday-Friday, May 28 through August 9 at the followng locations C~v~c Center Park Phoemx Park Owsley Neighborhood Dema Park MLK Recreation Center TWU Clubhouse Program Village East Apartments Houston Elementary School Rayzor Elementary School If you have any questions please contact me at extension 8125 Brenda Burton "Dedicated to Qualtty Serwce" SUMMER FOOD SERVICE PROGRAM FOR CHILDREN CRIMINAL PROVISIONS AND PENALTIES 1 Whoever, In connection with any application, procurement, record keeping entry, claim for reimbursement, or other document or statement made In connection with the program, knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or whoever in connection with the program knowingly makes an opportunity for any person to defraud the United States or does or omits to do any act with intent to enable any person to defraud the United States, shall be fined not more than $10,000 or Imprisoned not more than five years 2 Whoever being a partner, officer, director, or managing agent connected in any capacity with any partner- ship, ssaoolstlon, oooporatlon, business, or organization, either public or private, embezzles, misapplies, steals, or obtains by fraud, false statement or forgery, any benefits provided by the program, or any money, funds, assets, or property derived from benefits provided by this program, shall be fines not more than $10,000 or Imprisoned for not more than five years or both If the benefits, money, funds, assets, or property Involved is:not over $200, then the penalty shall be s fine of not more than $1,000 or imprisonment for not more than one year, or both 3 If two or more persona conspire or collude to accomplish any act made unlawful under this subsection, and one or more such person commit any act to effect the object of conspiracy or collusion, esuh shall be fined not more than $10,000 or Imprisoned for not more than five years, or both TERMINATION PROCEDURES The following list of deficiencies are grounds for termination Grounds for termination, however, are not limited to this list 1 Non-compliance with applicable bid procedures and contract roqulromenta of Federal Child Nutrition regu- lations 2. The submission of false Information to the Texas Department of Human Services (DHS) 3 Program violations at a significant proportion of the sponsors' sites Such violations Include but are not Ilmltsd to the following A Non.compliance with the meal service time restrictions B Failure to maintain accurate records. C Failures to adjust meal orders to conform to the variations In the number of portlclpotlng chlldrem D The simultaneous service of more than one meal to any child E Service of a significant number of meals which do not Include required quantities of all meal components F. The claiming of program payments for meals not served to participating children. G Excsaalve instances of off.site meal consumption H Continued use of food service management companies that are in violation of health codes AGREEMENT TO FURNISH FOOD SERVICE CITY OF DENTON and DENTON INDEPENDENT SCHOOL DISTRICT FOOD SERVICES THIS AGREEMENT is made and entered into by and between the Denton Independent School Dl;~tnC~ and the City_ of Denton Denton Independent School District agrees to supply umtlzed meals inclusive of hulk and juice to the City of Denton Parks and Recreation Department, at the MLK Recreatton Center, Phoemx Park, Dema Park, Clwc Center Park, Owsley Netghborhood, TWU Playhouse Program, Village East Apartments, Sam Houston Elementary Summer School, and Razor Elementary Summer School, vath and for the rates herein hsted Breakfasts $ 0 00 each Lunches $ 1 55 each Snacks $ 0 00 each Supper $ 0,00 each It is further agreed that the Denton Independent School District, pursuant to the provtstons of the Summer Food Sennce Program Regulattons, a copy ofwluch ts attached as Exhibit "A" and ts part of thts agreement, vnll assure that said meals meet the nummum requirements as to nutnuve value and content as outhned m the U S D A's Sponsor Meal PreparaUon Handbook, and vall maintain full and accurate recordings of such, including the following 1 Menu Records, including amount of food prepared 2 Meals, including datly number of meals delivered by type These records must be reported to the institution promptly at the end of each month Denton Independent School District agrees also to retmn records required under the preceding clause for a period of three years and 90 days after the end of the contract period If audits, clatms or htlgation have not been resolved, all records must be retained beyond the required time period untd all issues are resolved m accordance w~th the Summer Food Sermce Program Agreement between The C~tv of Denton and The Texas Department of Human Services The Denton Independent School D~stnct agrees to comply w~th the requirements of the Immigration Reform Control Act of 1986 regarding emplovment verification and retention of verification forms for any lndiwduals hired after November 6, 1986 who w~ll perform labor or services under this contract The Denton Indenendent School District agrees to allow for purposes of audit, exanunauon, excerpt, and transcription, the USDA, the Comptroller of the Umted States, D S and any of their authonzed representatives to have access to any of the contractor's books, documents, papers, and records that are pertinent to the contract The Denton Independent School D~stnct agrees to comply w~th the requtred mandatory standards and pohc~es concermng energy efficiency contmned in the Texas Energy Conservation Plan ~ssued in compliance w~th the Energy Policy and Conservation Act (P L 94-163) The Denton Independent School District agrees that except for small purchase contracts, prowsions that allow for adnumstrat~ve, contractual, or legal remedies If contractors xaolate or breach contract terms, and any appropriate sanctions and penalties The Denton Ind~endent School District agrees to be in compliance w~th S ectton 103 of the contract Work Hours and Safety Standards Act (40 USC 327-330) as supplemented by the department of Labor regulations (29 CFR, Part 5) Under tlus Act, contractors must compute the wages of mechamcs and laborers on the basis of a standard work day of e~ght hours and a standard work week of 40 hours Work that exceeds the standards must be compensated at least 1 ~A Umes the basic pay rate for overtime hours worked These reqmrements do not apply to the purchase of supphes or materials ordinarily available on the open market or contracts for transportation The Denton Independent School District agrees to comply v~th Executive Order 11246 entitled "Equal Employment Opportumty" as amended by ExecuUve Order 11375 and as supplemented m Department of Labor regulattons (41 CFR, Part 60) The Denton Independent School Dtstnct agrees to comply w~th all other apphcable laws, tnclud~ng w~thout hrmtatton, any additional apphcable Federal Laws or regulations contained m the Summer Food Semce Pro.am Aureement between the Cl_ty of Denton and the Texas Deoartment of Human Services If the Denton Ind~endent School District fads to proxqde sepaces m accordance vath the prows~ons of th~s contract, the City of Denton may, upon written notice of default to the contractor, ~mmediately ternunate the whole or any part oftlus contract The agreement shall be effective as of~_~_y_~ 1996 It may be terminated by not,ce m writing ~ven by any party hereto to the other pames at least 30 days prior to the date ofterrmnat~on IN WITNESS WHEREOF, the part,es hereto have executed tlus agreement as oftbe dates indicated below Agreed to th~s date. Agreed to flus date. Sponsor Offlc,al ~ S ch°°l Sp°ns°r~tff-~ ~ff~ ~"~L6 T~tle Acttn~ City_ Manager Title DISD School Board President The location of the food preparation s~te roll be Houston Elementary School, 3100 Teasley Denton, Texas, 76205 Texa.t ~ FOR DHS UeE ONLY of Huma~ Sa~ms SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION TX Owslay Park (817) 566-8125 Stella Denton, Texas 76201 Number of Op- May ~Jum20 .,mo Fmm 5/28/96 8/9/96 4 22 7 Al'tACH A MAP ~ THE SITE SERVICE AREA IDENTIP/,:D Re~lden~l Camp 1 Indicate Type of Site [] A.(#rdngonetefourmeal8) I I C (~ervlngonetefourmealq [] E (ser4ng one to four mea~) I-'lB NonmsldenUal Camp ,--t Site ~efvlng Primarily Homele# Children (lerdngonetefourmeab) I I D (eer/Ingonetefourmeals) Denton ~ List ALL ooundes sewed by this site _ []Yes [] No 3 A, Isyourelteopon DYes ~"INo B Is your site enrolled? 19 % C Site EligibilitY' Eater Ute Pefcentage °f children ehoible f°r free anc~°r reduced prim me~s f~ ~e s~ (SFSP H~ C~r il) mentetlon 8u rtin this percentage figure (such as census date school date) Fo.r. ope? e~s u~.ng school data, D f open sites, submit docu ppo g ......... ~..^, .,o. ,,..,-tabhsh ,mrcenmfle el irce & reaucoo pace children list the schools used to document site eligibility;, attecn lormu a usuu uy ~,,~, - ..... ,'- --,, Census data from TACAA E For anrolled eitee, Form 1531 will be uced to document eligibIlI~ If the enrolled ere used school data, list the school used to document the site 100 % F What is the percentage of free or reduced price meals for the site? Ely- D.o 4 Did the site p~llldl~te in previous yearn' SFSP? (SFSP Handbook, Chapter II) City of Denton ff Yes, give name of cantrao~ng organization MOrl;~ad~-,G Plan (-~FSP Hei~--~ Ch~-P~r III) Enter date of monitoring review to be conducted within 5 e I A. Fl~t Week et Ope(a9o~ l 5/31/96 6/12/96 7/17/96 6 Meal Service Period Information Lunch 7 Do you plan to feed ~hlldran under one (1) year old'/ []Ye~ [] No 8 I~e:,%G~ of Fond F~--~--~ ''~::'~ by C~`~' ~''~§ o~;;-~a~' (8FSP Han~K chapter II) , Fern1160WPaOe 2 9 Indicate the ~ystem to be used for the serving of meals and the supe~ion of children during meal sewlca period (SFSP Handbook. Chapter II) [-,~ Cafeteria. style r--1 Children ere Seated ~ Children Line Up I---I Meal ~efYl~e I I and are Given Meale I~1 end Ph=k Up Meale i i Other- 10 List site personnel who will be thvohrsd to any extent in the mesi sendno. ($FSP Handbook, Chapter II) ~ o~ FeStoON NO IN/)O~ITON SPECIFIC FOOD SERVICE PROGRAM DUTIES Site Supervisor 1 Supervise and assist distribution of mels, monitor and maintain meal temperature, site clean-ua, and other duties as assigned Site Helper/Server 1 A~st s~t~ SltT~i~l'V~q('11~ 11 Indicate what provisions will be made for meal service during periods of Inclement weather (SFSP H~nddook. Chapter II) Indw MMI r.--I Msel Service ~18erdee I IWIII Be Cancelled [-'lOther 12. ff the elto fcad8 ~ma~iy homeless children, what methods ars used to ensure that money, food stamps, or in-kind 8andces are not required for meals? n/a 13, )~e nIMiL1 peliverecl to the alta? ['~ Yes IF YES, COMPL=, lC, ITEMS 14, 16, & 16 IF NO, FORM IS COMPLIr. I c EXCEPT FOR CERTIFICATION AT BoI'rOM 14 Indicate the means of communication with the vendor which will be used to adjust meal deliveries ($F:$P Handbook, Chap II) i~ Site Personnel Will Canteat Admlnisbatlve i--t Site Personnel Will Comrnualcato · ;df, Who will Conte~t Vendor I I Dire=dy With Vendor 15 Wifl dalivefy be within one hour of the food service period? (SFSP Handbook. Chapter II) []Yes [] No ff no, ~ arrsngantants within standards prescribed by local health authorities for delMiry end holding of meal8 until dme of 8ewl~e 16 If there is an e~_,~___~ of meals delivered, meals will be (SFSP Handbook, Chapter III) ]Stored bt Rofdgorater i--iThrown Away r~ Ratumed to Vendor and 6awed the Neat Day llat the Site I Ilar Dle~,~__e! I-.JOthe~. l CERTIFY that the Inf~ on this from is has the (~ojibilll~d facilities for ~ meal service planned for the number of children anticipated I know that deliberate mlsrspresanta~n or wlthhofdb~of Info. ben ~sult In prosecution under appilr, aple state and federal statutes I Rick Svehla ~fn~ ACLU OF VIRGINIA F.4X Bill Coop~ ~4p4,f119, 0206022 270 138 .~-- :, :3= Form l~OT~ecember 1994 Texas ~ FOR DH9 USE ON~.Y d ,uman Sen~ SUMMER FOOD SERVICE PROGRAM FOR CHILDREN S~E INFORMATION Te~--~ ( I001 Parvin Denton, Texas 76201 F~ 5/28/96 m~h 8/9/96 I ~ACH A ~P W~ ~E S~ SERVICE AR~ IDENT~r~ ~ R~n~ ~mp ~ S~ ~wlng Pdm~y Migrant Chilton ~ ~r S~ 1 In~teT~ofS~e ~(~i~o~fourm ) ~C.(MwlngoM~f~r~b) ~E(Mwi~Me~rm~b) B (M~g Me ~ ~r ~) ~ D (;~l~ one ~ ~ur mob) 2 ~ ~ ~undes 8e~ ~ ~ 8~ Denton 3 A Is~rs~o~ . ~Ye, ~Ho B Is~rs~ en~l~? ~ % I~ ~e ~b ~ ~ ~mnt s~ eliglblll~ a~ ~ula u~d by ~1 d,sL ~ establ~h ~r~nmge of ~ & ~u~ p~ ~i~refl Census data from TAC~ E F~ enml~ s~s, Fo~ 1~1 ~1~ ~ us~ m d~ment efi~bill~ If ~e en~l~ ~ us~ ~ dam, fist ~ s~l us~ ~ d~ment 100 F ~t I~ ~e ~ge M ~e ~ redu~-p~ ~ for ~e If Y~, 9~ na~ of ~ng o~don 5 M~,;~;;r,G PI~ (ur~P RGr:~A, Cii~p;Gr Iff) E~;~; dste of moni~Hng r~i~ ~/~/~ ~/~/~ 6 Meal~6~l''l~''''=G~''{~r~r ~"~'~v~'~'" 7 ~ ~ pl~ W 1~ ~1~ un~r one (1) ye~ ~d? ~Yfl ~ No Fon~ lSOT)Nge 2 9 Indicate the system to be used for the sewing of meals and the supewlslon of children dudng meal sewlco pedod (SFSP Handbook, Chapter II) r--iCofaledl'atYle r'-t Children em Seated r'~ Children Line Up Meal ~lce I I and ere Given Meal. ~ and Pick Up Mesls [] Other 10 Uat site personnel who will be involved to any extent in the meal sewlco (SFSP Handbook, Chapter II) ~ O~ POsmON no IN pO~ItoN SPEOIRC FOOD SERVICE PROGRAM DUTIES Site Supervisor i Supervise and assist distribution of meals~ monitor and maintain meal temperatur% site clean-up~ and other duties as assigned 11 Indicate what provisions will be made for meal san4ce during periods of Inclement weather (SFSP Handbook, Chapter It) Indo~' Meal ~ Meal Sewlce r'~"] 8enriM J IWIll Be CAncelled []Other 12. ff ~e ~te fl~e~s p~ma~ hem~ess children, what me~od, are used to ensure ~at money, food s'=mps, er In.~nd ~an~ces ue not req~red fl)r me.k? n/a 13 Am meNs delNored tothes~e? []Yes •No IF YES, COMPLETE ITEMS 14, 15, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERllFICAl~ON AT SOT~OM 14 Indk:ate fie means of ceremurflce~on v~h the vendor which will be used to adjust meal del~e~es ($PSP Handbook, Chap II) F~e ~eraconol t~ll Can~-t Admlnls~itve ~ S~e Pemonnsl ~ll Cemmunlaate $~ff, Wbe ~]1Ce~I~ Vender I IDireeby ~lth Vendor 15 Will detivan/be within one hour of the food service period? (SFSP Handbook, Chapter II) r['lYas [] No If no, bescdbe alTangements within standards prescribed by local health autho~itea for al.liVely and holding of meals until time of sewlco 16 If there is an em of meals delivered, mew will be (SFSP Handbook, Chapter III) r~O~d In Rofrlgemer i--IThrowe Away r-.~ Returned to Vender Ind ~ewed the Next Day Iiat the S~e I IIM DI~-,~_~! I I~ I CERTIFY that the Infermaiton on this fomt la tm. and correct to the beet of my knowledge. I certify that this site has been visited and that It has ~e oaR~dl#y~md facilities for the meal sewlce planned for the number of children anticipated I know that deliberate mlsrepfesontetion or withholdln~ of Infol~ nm~ result in prosecution under applicable stet" and federal statutes I I City of Denton Rick Svehla Actin~ Cit~ Manaaer I ACLU OF VIRGINIA FAX 40,~11o. 1~ ~ H~ SUMMER FOOD SERVICE PROGRAM FOR CHILDREN I FM D~ USE ~NLY I 1400 M~ne Den~exas ~._~6201 , ,~.~ ~ X~ F~ 6 3 96 ~ h. e~ ~ ~ R~en~ ~mp ~ S~ ~wl~ Pdm~ly ~gmnt Chl~n ~ ~ S~ 1 iedi~T~of S~ ~ ~(~oneto~r~18) ~ C (Mwlngone~urm~) ~ E (Mwi~oMto~urm~) ~B Nonmiden~ Camp ~ S~ ~wing PHma~ Home~ Children (Mwi~oM~tm~) ~ D.(~wi~oMtof~rm~b) De~o~ 3 A 18~rB~o~n: ~Ye8 ~Ho B 18 ~ur 8~ envied? C S~ ~lgl~l~ ~ ~ ~ of ~l~ e~le ~r ~ ~ ~u~ pn~ ~als f~ ~e s~ (SFSP H~k, ~r II) 0 o~ u ~,~n~n supping · s ~nmge figure (such = ~nsus dam, s~t data) For o~n s~s using ~1 da~ D If o~n e~, s ~ --:- ,. ............. ,.~.,..~ .. ~ disL = es~blish ~r~n~e of frae & r~u~ prim ~ildmn E For enrolled aires, Form 1531 will be used to dooumant eligibility If the enrofied site used school data, list the school used to document the site 100 % F What is the pernentage of free or reduced pdce meals for the site? DY- 4 Did the site p~tl~ip~te In previous years' SFSP? (SFSP Handbook, Chl~tar II) If Yes, give neme of oontranUng organization Meal Sewtoo Period Information I IFSP Handbook, Chapter II} TypP.~ OF M~U.~ Breidda~t A M Supplement Lunch P M Supplement I-Iy. 7 Do you plan to feed ofdldran under one (1) yeir old? 8 Methed of Food preparabon by C~nt~actthg Organization (SFSP Handbo°k, Cheptor II) g Indic:ate the system to be used for the sewing of meals end the supewislan of children dudno meal sewice period (SFSP Handbook, Chapter II) i--1Cofeteda'MYle r'~ Children am Seated ~ Children Line Up Meal Sewise I I and,,re Given Meals ~ and Pick Up Meals [] Other* 10 Uet site personnel who will be involved to any extent in the meal 8ewico (SFSP Handbook, Chapter II) Supervisor 1 Supervise and assist distribution of meal m. mnnt~nr and maintain meal tempsrature, site clean-up, and other duties as assisned Site Hslpsr/Server 2 Assist site supervisor 11 Indicmte what provisions will be mede for meal service during periods of inclement weather (SFSP Handbook, Chapter II) Isdnor Meal Meal Service r"~ Sewk=e will Be Cancelled DOther 12, If ~ ~ Isede pdmmtly homeless children, what methods ~'e used to ensure that money, food stsmp~, or in kind sewises are not required fix meals? 13 Ammeaisbelivored tothealte? I- lyes I--'iNo IF YES, COMPLETE ITEMS 14, 15, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM 14 Indk~ate the means of communication with the vendor which will be used to adjust meal deliveries (SFSP Handbook, Chap II} r~ ~lte Pemmmal Will Ccot~t Admlslsb, aflve t--.iSite Pereennel Will Communicate Staff, Wbe Will Contect Vendor I IDImetly With Vendor 15 Will delivery be wills one hour of the food sewica period? (SFSP Handbook, Chapter II) []Yes [] No If no, describe arrangements within standards prescribed by local health authorities for bellvep/and holdlng of mesis until time of servk:e. 16 If them Is an excase of meals dalwered, meals will pe (SFSP Handbook, Chapter Ill) ]Gteged th Refdgeretor r.--iThrewn Away r.-t Returned to Vendor end Sen~d the Next OW I ilttheSIte I 1for DIepo~I []Other:. I CERTIFY that the Information on this form Is true and correct to tho best of my knowledge I certify that this alta has been visited and that It has thecmpmp~qtiy, and facilities for the meal eewi(~e planned for the number of children anticipated I know that deliberate mleraprseenta~on or withbeldipg'-of Info~pnedon may,jesuIt in prosecution under applicable state and federal statutes City of Denton Rick Svehla Ace~n~ Ct tv Hnn~o~r I Form l~O?~c~n~er 1~94 Texas D~ FOR DHS U~E ONLY ~ '~ ~ SUMMER FOOD SERVICE PROGRAM FOR CHILDREN S~E INFORMATION ~~ (8~7) 566-8125 ~ (s~,~,~ ~ E~f~o~d Cou~ De~o~, ~exas 7620[ From 5/28/96 ~h, 8/9/~6 ~ D~, ~ACH A ~ ~ ~E 8~ SER~CE AR~ IDE~i~ ~ R~denhl~mp S~ ~w~g Frilly Migrant Chilton 1 Ind~teT~ofS~ ~j k(~l~oM~four~b) ~ C (~l~one~hurm.l,) ~ E (.wlngonemfourm~) ~ Non~lden~ Camp S~ ~ng P~ma~ Homeh. Children B,(.wl~ ~ ~ f~r re.h) ~ D (.wl~ one to ~r m.~) 2 ~ A~ ~n~es se~d ~ ~ s~ Dent on 3 ~ Isyours~n DYe, ~No B Is ~ur s~ enmll~? ~ me ~]s ~ ~ a~ni she ellglDIIl~ 8~ Io~ulu u~u u~ E F~ enmllK s~s, Fora 1~1 ~11 ~ us~ to d~ment eliglblli~ if ~e en~l~ 8~ us~ ~1 dB~, list ~e s~l u~ ~ d~ment ~e site. 100 4 ~d ~ ~ ~ In p~s ye~' SFSP? (SFSP Hand~o~ Chap~r II) If Yes, g~ na~ of ~n~a~ng o~on Ci t y o f D e n t o n I 6 Meal Se~ Fe~ I,~1o,,,~, [~P~r -m,~ u""~m' ,v NUmb~ OF ~E8 ~ M~ WGIB~ C~REN BeGiNNiNG 100pm ~n~ 55 12 O0 p m 7 ~ ~ P~ m f~ ~lldm uMer one (1) ~ oM? ~Yes ~ No 8 M-&~ M F~ P~"~ 9 thdioste the system to be used for the sewing of meals and the super/sion of chlldre~ during meal sei~e period (SFSP Handbook, Chapter II) r--jCafalerta.styis r--i Children are Seated m~ Children Line Up Msel Senrise I I and am GIven Meals ~ and Plctk Up Meals [] Other 10 blat site personnel who will be involved to any extent in the meal ~en,,l~e (SFSP Handbook, Ch~oter Il). ~ oF FOanlON NO ~ I)O~ON aPECIFto FOOD SERVICE PROORAM S~Lt:e Supet'v'isot* ! Super'vise at~d dist:~'ibul:e meal. s, monit:o~' and meal. t:empe~'atut'e, sit:e c.[ea~-up, othe[' dui:tea 11 Indicate what provisions will be made for meal service during periods of Inch~ment weather (SFSP Handbook, Chapter II) i~,-iindoor Meal r-~ Meal Service ~ewise I IWlll 9e Cancelled []Other 12. If the ~te feeds prirnsdl,/homeless children, what methods are used to ensure that money, food stamps, or in-Mhd sewices are not required for meals? 13 ),J'emealsdoliveredtothasito? [ Yea i--INo IF YES, COMPLI='i ~ ii'EMS 14, 16, & 16 IF NO, FORM IS COMPLI: ] I~ EXCEPT FOR CERTIFICATION AT BOTTOM 14 Inri._lc~_~ the meaJ~ of oommunicstion with the vendor which will be used to edjust meal deliveries (SFSP Handoook, Chap II) f-~ 6ifa Per~mlnel Will Contact Administrative T-,-1 $~te Personnal Will Communl(~te 8taft, Who Will Contact Vendor tiDIre~tl¥ With Vendor 15 WIll dalively be wtth~ one hour of the food sen/ice perkxl? (SFSP Handbook, Chapter II) []Yea [] No If no, describe arrangements w~thin standards prescdbod by local haalth authorities for delivery arid holding of msEis until time of sense 16 If Ihare Is an ex__~__, of mens daliverod, meals will be (SFSP Handbook, Chapter Ill) F-,,.~ Stered In Refrigerator i.--iThrown Away r--~ Returned to Vendor I~d ~m~ed the Next Day I IsttheSife I Ifor Oisponal r-Tothar: I CERTIFY that the Information oo this form Is true and con'eof to the best of my knowledge. I certify that this site has been visited and that If has ~he..ea~ll~F~ facilities for the meal sewioe Wanned for the number of children anticipated I know that deliberate mIsrepresentation or wlthlxito~ of Intol~haifpn may resu~th prosecution under applicable state and federal statutes t Date IIMmeM (~il ~,M,w I)l~e ~. palm) TM I ~.$c~. $veh[a Ac~:lr~ City Ha~a~e~ I lee A CL U OF VIRGINIA FAX FRO~: ~#1 FO~111 ~O?~oetlgaer 1994 ~,~ SUMMER POOD SERVICE PROGRAM FOR CHILDREN I ,OR OHS US~ ~LY ........... ~ffE INFORMATION I ~ 01 A~ACH A ~P ~ ~E S~ SERVICE AR~ IDE~RED ~r S~ ~ R~den~ ~mp ~ S~ ~wl~ pd~ly MIgmM Children I Indl~of8~ ~ ~(~wl~etofoure.lt) ~ C (.wlngone~ure--a) ~ E (.wlngone~ur~b) ~ ~mlden~l Camp ~ S~ ~wlng PHmH~ Home~ Chlld~ B (~w~g~etofourm~) ~ D (aewl~one~urm~) Dento~ 2 U~mun~eaae~d~aa~ ~Yes ~No 3 ~ Isy~rsi~o~n ~Yea ~No B Is~rs~enml~d? [00 % C S~ ~igi~l~~ ~m~ ~ ~i~mn el~ f°r f~ ~ ~u~ pn~ meals f~ ~e s~ (SFSP Hand~ C~r II) i ~n~ · fl um (su~ ~ ~nsus da~. s~l data) For o~n s~ sub~t ~men~n supping · s ~. g g ~nm · of ~ & ~u~ PH~ ~ildmn D If o~n , sed b ~ d sL ~ es~blish ~ g I~t ~e ~ 8 ~ ~ d~ment are eliglblll~ a~ m~u~ u Y Cehsus data from TAC~ E F~ enmll~ s~8, Fo~ 1~1 ~lJ ~ ~ to d~ment eligibill~ If ~e en~l~ s~ us~ ~1 dam, list ~e s~l us~ ~ d~ment ~e s~. F ~at b ~e ~n~e ~ ~e or mdu~d-~ mens for ~e s~? 4~ ~e ~ ~paW ~ ~s yem' 8FSP? (SFSP Hand~ Ch~Wr II) ~y~, g~ na~ of ~n~ng o~on City of Denton 5M~flng PI~ (~FSP H~d~ Chap~r III) Enter da~ of mon~flng re~ ~ be ~ndu~ed w~in 6 Meal Se~ Pe~ Inf~ (SFSP H~d~o~ Ch~r II) ~. ~ ~ ~GIB~ CHI~REN ~ BE 8~ BEGIH~HG Bm~t A M 8upplem~t ~ O0 ~ ~n~ 50 ~2 O0 p ~ P M ~u~ ~r 7 ~ ~ P~ ~ ~ ~f~ u~er one (1) ~ ~ Ue~ ~ F~ ~ep~ ~ C~n~ 0~ (SFSP H~ndb~ Ch~pmr II) 9 IndJ(~lte the system to be used for the serving of meals and the supervision of children during meal sewJce period (SFSP Handbook. Chapter II) T-,] Cahihide~P/le ~ Children am Seated ~ Children Line Up Meal SorvMe I I and em Given Meals I~f and Pick Up Msels L~ Other 10 Uat site pemonne! w~o will be involved to any extent in the meal service ($FSP Handbook, Chapter II} Site Supervisor 1 Supervise and assist distribution of meals, monitor and maintain meal temperature, site clean-up, and other duties as assisnsd Site Helper/Server 1 Assist site supervisor 11 Indlm~te whct provisions will be made for meal service during periods of inoMnmnt weather (SFSP Handbook, Chapter II) ]~.-j~cer Mm ~ Meal Servise Sewk;e I IWIII Be Cancelled [-'lOther 12. If the site feeds ixtmaflly homeless children, what methods are used to enaure that mmley, food atamp~, or in.kind se~ee$ are not required for meals? n/a 13 Are meals dallvered to the slte? r~yan i'~Ne IR YES, COMPL~I'E rr~M$14, 15, & 1 6 IF NO, FORM I$ COMPL= i = EXCEPT FOR CERTIFICATION AT BOTTOM 14 thdi(~te the means of oommuni¢~tion with the vendor which will be used to adjust meal deliverhie (SFSP Handbook, Chap II) ~] 81to Faremmal WIll Contact Administrative r-~ Site Personnel will Communl~cte Staff, Who Will Contact Vendor I IDirectly With Vender 1 5, Will deliver/be within one hour of the food service period? (SFSP Handbook, Chapter II) ~Yea [] No If no, describe an-angemenhi within standards prescdhad by local health authorities for deliver/and holding of melds until time of service 16 ff them is an ex~s of meals delivered, meals will be (SFSP Handbook, Chapter tit) i-.]~ ~'Aored M Refrigerator r.-.tThrewn AwW r--~ Returned to Vendor aed Sewed the Nexl Oiy I lattheSIte I Ifor Dlspesel I IOthen I CERTIFY that 1ho Infommifoo on this form hi true and oon, ant to the beat of my knowledge I certify that this site has been visited and that it has the ~a~abl~ and fadliifan for the meal senrioo planned for the number of children anticipated I know that dellbereto misrepresentation or withhofdillfl of InTon~alton ~ result in prose~uifoo under apptioabie state and federal statutes City of Dentnn i Rick Svehla Actin~ City Manager I ACLU OF VIRGINIA FAX FROM: BIll Cooler D,4FE.'. d~l I0, l~Z Form lff07~r 1994 Dep~ FOR DH$ USE ONt.Y ~ ~UMMER FOOD SER~CE PROGRAM FOR CHILDREN S~E INFORMATION ~_. ~ ~=~ (~ ~)12 ~~S~ (817) 566-8 Houston Elementary School 3100 Teasley Denton, Texas 76201 0/3/96 -.~==:=-~' 6/28/96 e~{~ 0~ 20 ~ACH A ~P ~ ~E S~ SERVICE AR~ IDEN ~ R~en~ ~mp ~ ~ S~ ~l~ P~ma~ly Mlgm~ Chilton Indl~T~of S~ ~ ~(~o~tof~rm ) ~ C (.~one~f~rm--~) ~ E (.wl~oneto~urm~) Non~en~l Camp ~ ~ ~g P~aH~ Home~ Ch~n ~ B (~ o~ ~ ~r m~b) ~ D (#w~ o~ ~ ~ur m~) ~ A~ ~unUes ~ ~ ~b s~ ~Y~ ~No Is~or s~ o~n ~yes ~No Is ~r s~ enrolled? ~ ~lgl~l~ ~ ~ of ~ e~e ~f~ ~ ~ pnm meals f~e s~ (S~P Hand~ C~r II) 0 ~n su o~n ~is ~nmge f gum (su~ ~ ~nsus da~ s~t da~) For o~n s~s u~ng ~1 d~ If o n s~, 8u~t ~n~ PP g ....... ..h~l ~i~t. m es lish ~r~n~e of ~ & r~u~ P~ ~ildmn I~t ~ ~ ~ ~ d~ s~ ellglbili~ a~ m~um u~ uy ............ mb _ __ E For enrolled sites, Font 1531 w#l be used to document eligiblli~y If the enrollod site used school data, list the school used to document the site. F What is the percentage of fres or reduced prtoo mesls for the site? 4 Did the site pa~ifctpeta In previous years' SFSP? (SFSP Handbook. Chapter II) If Yes, give name of oontm,~ng organization 5 Mor~;k~,r,§ Plan (SFSP H.--~-t-:<,~:. Chapter Iff) Enter date of monitoring review to be conducted within 4 96 1 Meal SeMoo Period Informeifon (SFSF .enaooo~ ~ NUMBER OF MEAL BERVICE TLME TYPEB OF I~I~U,.8 ELIGIBLE CHILDREN ~ BEGiNN~Ne ENDING i TO BE BERVEO* A M Supplement Lunch 30 11' 45am 12: 45am 7 Do you plen ~o l~cl ch#dmn under one {1} yenr 8 9 Indk=ate the system to be used for the sewing of meals and the supewls[on of children du~tng meal service peded (SFSP Handbook. Chapter Il) i--] Cafeisda-atyls r--.~ Children sm Seated ~ Children Ltne Up I-'1 Meal ~ervlse I I and -,re Olven Meals I~1 and Pick Up Meals L_J Other' 10 LJat site personnel who will be Involved to any extent in the meal sewice (SFSP Handbook, Chapter II) Site Supervisor 1 Supervise and distribute meals, monitor and maintain meal temperature, site clean-up, and other duties as assigned 11 Indicate v/nat provisions will be made for meal servi~ dudng periods of in~ement weather (SFSP Handbeok, Chapter II) Indoer Meal ~ Meal Service f'~tSewlse I IWIII Be Cancelled E~olher 12. If the Bite feeds pdmmtly hameisss children, whet methods are used to ensure that money, food stamps, or In-kind sewlce8 are not recluimcl fol' meads? 13 Am meals delivered to the site? r'~'lyas r-'lNo IF YES, COMPL=I'= ITEMS 14, 1 $, & 16 IF NO, FORM IS COMPLI:I = EXCEPT FOR CERTIFICATION AT Bo'rroM 14 Indicate the means of communicaifon with the vendor which will be used to adjust meal deliveries (SFSP Handbook, Chap II) i-~,leite Pere(msel Will Contact Admlnictratlve r~Site Pe~onnsl Will Communl~lte ~tatf, Who Will Conte~ Vendor I lDlmctly With Vendor 15 Will dallvely be within one hour of the food service period? (SFSP Handbook, Chapter II) I'~lyas [] No If no, dsecdbe anangemants within standards prescdhad by local health authorities for delivery and holding of meals until time of sewim 16 if there is an ex__,:e~_~ of meals delivered, meals will be (SFSP Handbook, Chapter III) i~ ~ored in Refrigerator r--1 Thrown Away ~ Returned to Vendor sed 8ewnd the Next Dey I lattheSife I Ifor Olapseal I'--IOther I CER'I1FY that the Infonnapon o~ this fofm Is tree end correct to the beat of my knowledge I certify that this site has been visited and that It has the cebe_.lillJ~ and fantll~as for the meal service planned for the number of children anticipated I know that deliberate micmpmasntapon or wtthhofdlnd'-of Inf~'rnaiton may [esuit In prosecution under applicable state and federal etetutea - ' //f ,~__ INameo~Oontm~nO(m'Oa~_-__-,~:,,,_ I Rick Svehla ~g~in~ Cftv M~n~r ~"~A~ [~] Denisd, me~on ,a~n ~ SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION TX Phoenix Park (817) 566-8125 Wood Street Denton, Texas 76201 #.tuber Fra~ 5/28/96 4 20 22 7 AI'rACH A MAP WITHITHE SITE SERVICE AREA IDENTII'I~I.~ ~ Rlmldentisl Camp le Site ~wlng Primarily Migrant Children ~ Other Site Indic~taTybe of Site L.J A.(#wisg~netafourmea ) [] C (lewisgenetafourmeai~) I~l E (#wlngenetofourmeal~) Nonresidential Camp r'-"t Site Serving Primarily Homle# Children [] B (~ervlng one fo four meals) I ID.(sewlngonetofourmealq Denton Ust ALL counties sewed by this site IYe. eno A. is your slte open. [:]Yes r'~'lNo B Is your site enrolled? 31 C Site Eiiglb#lty. Enter ~e percentage of chlldr~ eUg~le for free and/or reduced Pdce meals f~ ~e s~ ($FSP H~ C~r II) D If open sites, submit documentation supporting this percentage figure (such as census data, school data) For open sites using school data. list the ~ used to document site eliglblll~ attach formula used by school dist. to establish percentage of free & redumld price children Census data from TACAA E For enrolled sites, Form 1631 will be used to document eligibility If the enrolled site used school data, list the school used to document the site. ]~oo F What is the percentage of free or reduood-pdce meals for the site? Did the site pastfolpato in previous years' SFSP? (SFSP Handbook, Chapter II) r~yes [] No ff Yes, give name of contra~ng orgenizatinn City o f Denton MO.;~,~§ Plan (~F~P H~.~'='b'-=~k~ Chapter Ill) Enter date of monitoring review to be conducted within lA. Fim Week of O~em~o~ · 7/17/96 I 5/31/96 6/12/96 Meal Sefvfoe Pedod Infommtion TO Lunch 90 12 O0 p m 1 O0 p m P M ~._.~.;~,,ent 7 13o you plan to feed chlMren under one (1) yem' old? []Yes [] No 8 N;~:'~,o,~ of Food ~,-w ~ Iso7/Plge s g Indk:ate the system to be used for the sewing of meals and the supewision of cNIdren during meal semite period (SFSP Handbook, Chapter II) r--lCafeteria.etyle ~ Children are Seated ,-~ Children Uns Up Meal ~ervlse I I and are Given Meals ~XI and PMk Up Mania [] Other 10 Ual ~te personnel who will be Involved to any extent in the meal eswl;e. (SFSP Handbook, Chapter II) ~ OF POSITION NO In posmol; SPECIFIC FOOD 8ERViCE PROORAM DURE8 Site Supervisor 1 Supervise and assist distribution of meals, monitor and maintain meal temperature, site clean-up~ and other duties as assigned Site Helper/Server 1 Assist site suoervisor 11 Indicate what provisions will be made for meal sewins during periods of inclement weather (SFSP Handbook, Chapter II) r~l~Msel r.-~ Meal Sewioe I IWIll Be concelled []Other 12. If ~he ~dte feeds pdmadly homeless c~lldren, what methods are used to ensure that money, food alamps, or In Idnd sewises are not re~dred for meals? n/a 13 Am meal8 deliv~ed to the sim? I""~"lyes I'--'1 No IF YES, COMPLETE ITEMS 14, 1S, & 16 IF NO, FORM IS COMPL,-i,- EXCEPT FOR CERTIFICATION AT BOTTOM 14 IndiGOs the means of communication wi~ the vendor wh~ will be used to adjust meal delivartes (SFSP Handbeok, Chap I~) r~lSite personnel Will Contact Administrative ~..t Site Pemonnsl Will Communlvete Staff, Who Will Contl~t Vendor L._I DlrecUy With Vendor 15 WIll delivery be within o~e hour of the food service period? (SFiP Handbook, Chapter II) []Yes [] Ho If no, clse~be arrangements wl~m standarcis pmsartbod by local health authorStles for delrvan/and holding of meals u~l time of service 16 If there Is an exness of meals delivered, meals will be (SFSP Handbook, Chapter III) ]Stemd In Refrigerator r.-.~Thrown Awiy r--~Retumed to Vandm* Ired Sanmd tbe Next COy L.JBt the Site L..J for Dbpnsal []Other' I CERTIFY that the Information on this fom~ io tn~a and correct to the beat of my knowledge. I cortffy that this site has been visited and that If has the cop.~ldlifyll~d facilities for the meal nervioe planned for the number of children ontlalpatod I know that deliberate mIsmpresontaifon or withholdj, l[of Infmzjiat;..on may m~alt In prosanut~on under appli=abie state and federal atatutea  I City of Denton Rick Svehla Acginm City Manamev 02~,~ 2 lO~e ~S'7. ?7 71% From l~?~emmber 1994 ~ SUMMER FOOD EERVICE PROGRAM FOR CHILDREN I S~E INFORMATION ~ Civic Center Park 321 E McKinney Denton, Texas 76201 5/28/96 ~ h: 8/9/96 e~go~e r ~ ~ACH A MAP ~ ~E ~ SER~CE AR~ IDEatED ~ R~en~ ~mp ~ ~ ~wlng PHmaHly ~g~t ChlMmn ~r SHe U~ A~ ~undes ~d ~ ~b S~ ~ Y~ ~ No Is~rs~ o~. ~Yee Is ~r s~ enml~d? S~ EIIglblll~ ~ ~ ~e d ~M~ eflg~ ~ ~ ~ ~ pdm me~ f~ ~e s~ (SFSP Hand~ C~r Il) 2 2 % n su · ~ s ~n~e figure (su~ M ~us date, ~1 d~ta) For o~n Ce~us data [~om TAC~ ~at M ~ ~n~ge M ~ or mdu~d-pH~ meals for ~e ~ me ~ ~d~m M ~us ye~' SFSP? (SFSP Hand~ Chafer II) ~Y~ ~ No Yes, g~ n~ of ~ng Me~ SeMm Pe~ Info--don (SFSP H~db~ Char II) NU~ER OF M~ ~ER~CE ~ ~ BE 8ERVW BEGIN~NG Bm~t A M Supple~nt ~n~ ' 40 ~2 00 p m ~ 00 P M. Sup~ement 8~r ~ ~ ~ ~ f~ ~dr~ uMer one (1) ye~ old? ~Y" ~ No 9 Indk~te the Wetern ~ be used for the san~ng of meals and the eupe~sJon of children dudng meal se~ce perio~ (SF~P I..landboo~ Chapter II) ~Cafetef~Myte ~ Children are Seated ~ Children Line Up Meal hndce I I and are Given Meals i~1 and Pick Up Meals [] Other 10 Ust alte personnel who w~ll be Involved to any extent in the meal service. (SFgP Handbook, Chapter II) ~ OF Festoon NO D4 Festoon 6PECIFIC FOOD 8EnVICE PnOGn&M DUTIES Site Supervisor 1 Supervise and assist distribution of meals, monitor and maintain meal temperature, site clean-up and other duties as assisned 11 Indicate what provhih~ns will be made for meal sewice dudng periods of inciement weather (SFSP Handbook, Chapter II) i~-i~Meal r-..~ Meal Service I Iwill Be Cancelled []Other 12. If ibe s~te feeds pdm&.lly homeless children, what methods are used to ensure that money, food stamps, or In-ldnd sel~lces are not required for meals? n/a 13, Am meals dalivemd to the site? i~yoo []No IP YES, COMPLJ: i,- ITEMS 14, 1S, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM 14 Indh:ate the means of communication with the vendor which will be used to adjust meal daliveries (SFSF HandbooK, Chap II) i-~1 Site Perscenal Will Contact Admlniatretlve I-'1 Site Pemannol Will Communicate Staff, Who Wlif Contact Vendor I IDirectly With Vendor 1 $ Will deliver/be within one hour of the food service benod? ($F:SP Handbook, Chapter II) [] Yes [] No If no, dsechbe an'angemenhi within standards prescribed by local health lu,,thoritise for daliver/end holding of melds until time of 8ewloe 16 If there is an excess of meals delivered, meads will be (SFSP Handbook, Chapter III) r~Stored M Refdgerstor r.-IThrown Away r--~ Returned to Vendor and Sewed the Next D~y lilt me SIfe L_Jter Dhipoeal []Other:. I CERTIFY that the Informa~on on thhi form hi true and cerrect to the best of my knowledge I certify that this site has been vlalted and that It has the ~lify and factlltlse for the meal .ewhie planned for the number of children anticipated I know that deliberate mhirepresenteifoo or wlthbeld~fOnllation ~ result In prosecution under apellcabhi state and federal $tetute$ - , / City of Denton D~ t Rick Svehla Acting City Manager ~ ACLU OF VIRGINIA FAX 3 mi. C,,,etu~ ~) ~ ~#1 ~ ~i 1o. ~ Fo~rn 1807~lcemb~t ~4 ~ N~,n..'~ ~ SUMMER FOOD SERVI~E PROGRAM FOR CHILDREN S~E INFORMATION ~ I ~ (817) 366-812~ ~ ~300 N~son Denton, Texas 7620~ ~ A~ACH A MAP W~ ~E S~ SER~CE AR~ R~en~l ~mp ~ S~ ~wlng PHmaHly ~gmnt ChlMmn ~r S~ 1 Ind~T~ of S~ ~ ~(~o~to~urmm) ~ C {~l~one~urm~) ~ E (~ngo~fourm~) ~mMen~ Clmp ~ S~ ~wing P~ Homel.~ Children ~ B (~e~urm~) ~ D (eewl~ one to four m~) B ls~rs~enml~d? ~Yes ~No su~it ~men~Gon supping ~la ~nmge figure (su~ M ~nsus date, s~l dam) For o~n s~es using ~ Census ~a~a [=om H ~e en~ S~ us~ ~OM ds~, ii~ ~e s~i us~ to d~ment ~e sRe. 100 % F ~t ~ ~ ~n~ge M ~ee or mdu~d-pH~ meals for ~e 4 ~ ~ s~ ~ b ~s yem' SF~P? (SFSP Hand.ok, Ch~ter il) ~Y~ ~ No If Yes, g~ na~ of ~n~a~ng o~Uon C ~ ~ y o ~ D e n C on 5 M~.o.ng P'~ (SFSP Ha~bg~ C.ip~r ,11) Enter ds~ of moni=.n; r~i~ ~ ~,~ndu=~ ~E8 ~ M~ ~QIB~ C~RBN E~NQ 7 ~ ~ pl~ ~ f~ ~ld~ ~der o~ (1) ye~ o~ ~Yes Fo~m 1 9 Indisete the system to be used for the sewing of manis end the supervision of c~ildren during meal ~ervlce period (SFiP Handbook, Chapter [-.] Cofeteda.atyio ~ Children am Seated ~ Children Line Up Meal Service ii and are Given Meaic I~1 and Pick Up Meals [] Other 10 UCt site bemonnel who will be Involved to any extent in the meal servioe ($FSP Handbook, Chapter II) ~ OF PO~"ION ! IlO IN Po~motl aPECIPIC FOOD aEavIca PROGRAM DU'TIEa Site Supervisor 1 Supervise and assist distribution of meals, monitor and maintain meal temperature, site clean-up, and other duties as assigned Site Helper/Server 1 Assist Supervisor 11 Indicate what pmvialons will be made for meal service during periods of Incfoment weather (SFSP Handbook, Chapter II) ~,.]lndoor Meal ~ Meal 6ervlce ~arvice I Iwili Be Cancelled []Other 12. ff the a~te feeds pdmmlly homeless children, what methods are used to ensure that money, food stamps, or In.ldnd sen'ices are not reCluh'ed for meals? 13 Am mseis dalivered to the site? [~Yee [].o IF YES, COMPLETE ITEMS 14, 15, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM 14 Indlmlte the means of communicetion with the vendor which will be used to adjust mseJ deliveries (SFSP Handbook, Chap II) r~sife pareonnal Will Conteat AdmlnlMratlve ~$1te Personnel Will Communicate Staff, Who Wlil Contact Vendor t IDIrectJy With Vendor 16 WIll dalivary be within one hour of the food service period? (SFSP Handbook, Chapter II) r~ye~ []No If no, descdbe arrangements within standards prescribed by local health authorities for dalwery and holding of meals until time of sendse 16 ff there b an exsese of meals delivered, melds will be (SFSP Handbook, Chapter tit) [:_~] Stored In Refrigerator r-.1Threwn Away r--~ Retemed to Vendor und ~arved the Nect D~y t IcttheSite iifor Dispunct [~] Ot~. I CERTIFY that the Information on this form is true and oorrant to the beat of my knowledge. I ~ertity that this site bee been Halted and that It him the I~QAbifity~nd fanifldan for the meal sewlce ptenned for the number of children antl(dpatod I know that deliberate mlsrapresentadan o~ wifhhold~ ~ Infgh~lIfon rnay/~eauIf in prosecution under applir, abie state ~nd federal statutes · / /2' // /f. Name01C.~ran~JngOf0amzeao, I ento Rick Svehla Actin~ City Manager I ACLU OF VIRGINIA FAX C,,,~,~m,~ ~,,,,) FOOD SERVICE PROGRAM AGREEME~NT STATE OF TEXAS COUNTY OF TRAVIS The Texas Department of Human Servicas, hereinafter referred to as TDHS, City Ao~DDenton 321 E McKinney Denton 76201 hereinafter referred to as the contractor, do hereby make and enter into this contract, as required by the National School Lunch Act (Section 13) and the Summer Food Service Program, hereafter referred to az the SFSP, Federal Regulatlom (7 Code of Federal Regulations [CFR], Part 225) I MUTUAL AGREEMENTS The pa_rues mutually agree A If the contractor fails to provide services m accordance with the provmions of this contract, the Department may, upon written horace of default to the contractor, immediately terminate the whole or any part of this contract and refuse to pay claims for reimbursement Such termination and/or refusal to pay claims for reimbursement shall not be exclusive remedy but shall be tn addition to any other mghta and remedlas provided by law or under this contract B If federal and state laws or other requlrement*~ are amended or judicially interpreted so that the continued fulfillment of this contract;' orr the part of etcher part},, Is substantially unreasonable or Impossible, or if the partlaz are unable to agree upon any amendment which would therefore be needed to enable the substantial continuation of the services contemplated by this contract, then the parties shall be discharged from any further obligations created under the terms of this contract, except for the equitable settlement of the r~pecuve accrued mterast or obligations, including audit findings, incurred up to the date of termination C This contract may be canceled by mutual consent However, if such mutual consent cannot be attained, then and in that event, either party to this contract may consider it to be canceled without cause by giving thirty (30) days notice in writing to the other party and this contract shall thereupon be canceled upon the expiraoon of such thirty (30) day period Nothing in thl.~ paragraph shall be construed to prohibit immediate eancellanon pursuant to above paragraphs A and/or B II CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT A The contractor w,ll comply with the SFSP Federal Regulations (7 CFR, Part 225, as amended), Uniform Federal Assistance Regulation (7 CFR, Part 3015, as amended), and state policies and procedures as issued and amended by TDH$ The contractor further agrees to perform as described in its application (including supporting documents and approved amendments to the epph;atlon) for parUcipaUon m the SFSP B The contractor accepts final admuustratlve and financ,al respons,bility for food service operations at each a,te sponsored by the contractor This respons]blhty includes the performance of. the coatt, tiou~ of eecdemanl.o~,.a~y and,l,except~ons or payment deficiency ,n the program and the collection and repayment of an), amount.pa,d m excess of the proper claim amount which are founil after monitoring or andl~ng by TDH$ or the Umted States Department of Agr, culture (USDA) Th,s responsibility applies to this contract, and all subcontracts hereunder C The contractor will apply to TDH$ for approval of changes to its original application and for prior author~zation for field trips ,f meals served on the field trips will be claimed for re,mbursement Requests for changes and field tr,p authorization must be received by TDH$ at least five (5) calendar days before the requested effective date for the change or the field trap Con~ractors will notify TDH$ with,n five (5) days of the termmauon of an approved food service site III SFSP RECORD I~k'~ING A The contractor will keep financial and supporting documents, staustical records, and any other records pertaining to the services for which a claim ~s submitted The records and documents will be kept for at least three (3) years and mnety (90) days after the term~n_~_uon of the contract period If any litigation, clann, or audit involving these records begins before the stipulated time per~od expires, the contractor will keep the records and documents for not less than three (3) years and ninety (90) days after the tennmauon of the contract period and until all litigation, cia,ms or audit findings are resolved The case ~s considered resolved when a final order is issued in litigation or a writtan agreement ts signed by TDHS and the contractor ]Extensions are considered as separate contract periods B The contractor and its subcontractors will allow TDHS and USDA officials and other appropriate officials determined by "I'DFI$ to inspect facilities and records and to anilit, examine, and copy records at any reasonable time This includes access to all records of costs paid, even in part, by TDFIS Noo 8e.h~ol $1~t~o~ - lh~ 2 CIVIL RIGHTS POLICY COMPLIANCE A The contractor agrees to comply with Title VI of the Civil Rights Act of 1964 (Public Law g8-352), and all requirements imposed by the regulat,ons of the Department of Agriculture (7 CFR, Parts 15, 1Sa and lSb) Department of Justice (28 CFR, Pans 42 and 50) and USDA and TDHS drreetlves or regulations issued pursuant to that Act or the regulations, Sect,on 504 of the Rehabilitation Act of 1973 (Public Law 93-112), The Americans with Disabfl,ties Act of 1990 (Public Law 101-336), and all amendments to each, and all requirements imposed by the regulations ,ssued pursuant to these acts In addit,on, the contractor agrees to comply with Title 40, Chapter 73, of the Texas Admu,,~tra~ve- Code These provzde in pan that no persons in the Untied States shall, on the grounds of race, color, nat,onal ong,n, sex, age, disability, pohucal beliefs or ral,gion be excluded fi.om pan,clpauon in, or denied, any aid, care, service or other benefits provided by federal and/or state funding, or otherwise be subjected to dlsonmmauon under any program or activity for which the contractor receives federal flnanc,al assistance from TDH$ and USDA and hereby gives assurance that it will lmmedtataly take any measures necessary to effectuate this agreement B The contractor agrees to comply with Texas Revised C~vd Statutes Article 441964, Sections 5 03 and 5 04 (relating to workplace and confidentiality guidelines regarding AIDS and HIV) C This assurance is given in consideration of and for the purpose of obtaining any and all federal financial assistance, grants and loans of federal fund, reimbursable expenditures, grant or, donation of federal property or interest in such property, the detail of federal personnel, the sale and lease of, and the permission to use, federal property or interest in such property or the furnishing of services without consideration or at a nominal consideration, or at a consideration which is reduced for the purpose of assisting the recipient, or in recognition of the public interest to be served by such sale, lease or furnishing of services to the recipient, or any improvements made with federal financial assistance extended to the contractor by TDHS This includes any federal agreement, arrangement, or other contract which has as one of its purposes the provision of assistance such as food, cash assistance for the purchase of food, rental of food service equipment or any other financial assistance extended in rehance on the representation and agreements made in this assurance D This assurance is binding on the contractor, its successors, tr~.-.sferees, and assignees as long as it receives assistance or retains possession of any assistance from TDHS or USDA The person whose signature appears on this contract Is authorized to make this assurance on behalf of the contractor V TDHS CLAIMS PAYMENT TDHS will, subject to the federal appropriation and avadabdlty to TDH$ of suffic~ant funds for the SFSP, m~ke program payments to the contractor m accordance with the terms of this contract No reimbursement shall be made for performance under this contact occurring prior to (a) the begiamng effective date of this contract or (b) a Inter date established by TDH$ based on the date of receipt of a fully executed copy of this contract Non School Sponsors - Page 3 VI CERTIFICATIONS A Immigrat,on Reform and Control Act of 1986 - The contractor agrees tO comply with the requ,raments of the Imm,grat,on Reform and Control Act of 1986 regarding employment verification and retention of verification forms for any individuals hired ai~er November 6, 1986, who wdl perform any labor or services under this contract B Regarding Debarment, Suspens,on, Inehg,bdlty, or Voluntarily Exrdnsion For Covered Contract~ - The contractor certifies, by execution of this agreement, that neither it nor ,ts prmc,pals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntardy excluded from parucipatmg in this contract by any federal department or agency or by the State of Texas By makang this cerdficauon the contractor agrees to the following terms 1 The above cert,fication is a material representation of fact upon which reltance wes placed when this contract was entered into If ,t is later determined that the contractor knowingly rendered an erroneous certlficat,on, in addition to other remedies available to the federal government, the Department of Health and Human Service,s, United States Department of Agriculture or other federal department or agency, or the Texas Department of Human Services may pursue available reined,es, including suspension and/or debarment 2 The contractor shell provide immediate written notice to the person to which this cerilficatlon is submitted if at any time the contractor learns that the certdficatlon wes erroneous when submitted or has become erroneous by reason of changed circumstances 3 The words "covered contract,' "debarred," "auspended," "ineligible," "partmipant," "person," "principal," "proposal," and "voluntarily excluded,' as used in this cenlficauon have meanings based upon materials in the Definitions and Coverage sections of federal rules implementing Executive Order 12549 Usage is as defined in the attachment 4 The contractor agrees by subm,ttmg this cemficat,on that, should the proposed covered contract be entered into, ,t shall not knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from pam¢]patiou in th~s covered transaction, unless author,,ed by the Department of Health and Human Services, United States Department of Agriculture or other federal depamnent ot agency, and/or the Texas Department of Human Services, as apphcable 5 The contractor further agrees by submitting this certification that it will include TDH$ Form 2046 mind "Cemficauon Regarding Debarment, Suspension, Inehgibdity, and Voluntary Exclusion for Covered Contracts" without modification, in all coveted subcontracts and in sohcitauons for all covered subcontracts 6 A contractor may rely upon a ceruficauon of a subcontractor that ~s not debarred, suspended, ineligible, or voluntarily excluded from the covered contract, unless it knows that the certtficat,on is erroneous A contractor must, at a minimum, obtam certlflcaUons from its covered subcontractors upon each subcontract's uuuauon and upon each renewal School Spoflso~ - Page 4 CERTIFICATIONS (continued) '/ Nothing contained m all the foregoing shall be construed to require establishment of a system of records m order to render in good faith the certification required by this certification document The knowledge and information of a contractor is not required to exceed that which is normally possessed by a prudent person m the ordinary course of business dealings 8 Except for contracts authorized under paragraph 4 of these terms, if a contractor m a covered contract knowingly enters into a covered subcontract with a person who Is suspended, debarred, ineligible, or voluntarily excluded from participation m this transaction, in addition to other remedies available to the federal government, Department of Health and Human Services, Umted States Department of Agriculture, or other federal department or agency, as applicable, and/or the Texas Department of Human Services may pursue available remedies, Including suspension and/or debarment C Regarding Federal Lobbying - This certification apphes only to this contract and is a material representation of fact upon which reliance was placed when this transaction was made or entered into Submission of this certification is a prerequisite for making or entering into this transaction ~mposed by section 1352, title 31, U S Code Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure The contractor certifies, to the best of his or her Lnowledge and belief, that I No federally appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress ;n connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement 2 ,If any funds other than fedesally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer employee of any agency, a member of congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federally funded contract, subcontract, subgrant, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions :3 The contractor shall require that the language of this certification be included in the award documents for all covered subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all covered subreciplents shall certify and disclose accordingly The contractor certifies that all reformation submitted pursuant to this agreement Is true and correct The contractor understands that the deliberate misrepresentation or withholding of information is a violation of this contract and may result in prosecution under applicable state and federal statutes Non Scltoo) Sponsors Page VII E~.sCTIVE DATE AND SIGNATURES For the fmthful performance of the renm of th~s contract, the pan,es hereto m their capac~t~ stated, affix their mgnatures and b~nd themselves City of Denton Name of the Contracting Orgnn,~'~Uon (Please Print or Type) Original s,gnature of the anthomzed representative of the contracting organ~at~on Rick Svehla Name of the authorized representative of the contracung orgamzataon (Please Print or Type) Acting City Manager T~fle Please print or type, m the spaces prowded above, the name and Utle of the author, ed reprezentauve mgmng thts agreement on behalf of the contracung organtzauon Effective Dates through By., Date Revtaed February 1994 SUMMER FOOD SERVICE PROGRAM AGREEMENT STATE OF TEXAS § COUNTY OF TRAVIS § The Texas Department of Human Services, hereinafter referred to as TDHS, AND City of Denton 321 E. McKinney Denton, Texas 76201 hereinafter referred to as the contractor, do hereby make and enter into this contract, as required by the National School Lunch Act (Sect,on 13) and the Summer Food Service Program, hereafter referred W as the SFSP, Federal Regulat,ons C7 Code of Federal Regulat,ons [CFR], Part 225) I MUTUAL AGREEMENTS The Parties mutually agree A If the contractor fails to provide services m accordance with the provisions of this contract, the Department may, upon written notice of default to the contractor, immediately terminate tho~ whole or any part of this contract and refuse to pay claims for reimbursement Such terlBlnatlon and/or refusal to pay claims for reimbursement shall not be exclusive remedy but shall be in addition to any other rights and remedies provided by law or under this contract B If federal and state laws or other requirements are amended or judicially interpreted so that the continued fulfillment of this contract, on the part of either party, is substantially unreasonable or impossible, or if the parties are unable to agree upon any amendment which would therefore be needed to enable the substantial continuation of the se~,lcas contemplated by this contract, then the parties shall be discharged from any further obligations created under the terms of this contract, except for the equitable settlement of the respective accrued lnter~t or obligations, including audit findings, incurred up to the date of termination C This contract may be canceled by mutual consent However, if such mutual consent cannot be attained, then and in that event, either party to this contract may consider it to be canceled without cause by giving thirty (30) days notice m writing to the other party and this contract shall thereupon be canceled upon the expiration of such thirty (30) day period Nothing in this paragraph shall be construed to prohibit immediate cancellation pursuant to above paragraphs A and/or B 11 CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT A The contractor wdl comply w~th the SFSP Federal Regulations (7 CFR, Part 225, as amended), Uniform Federal Assistance Regulation (7 CFR, Part 3015, as amended), and state pohcies and procedures as issued and amended by TDHS The contractor fmther agrees to perform as described m its apphcat~on (including supporting documents and approved amendments to the apphcation) for panzcipation m the SFSP B The contractor accepts final administrative and financial responslbdtty for food service operatzons at each szte sponsored by the contractor This responsiblhty includes the performance of. the condttmn~oL~mlemant, of..aay andlt,e~c, epttons or payment deficiency In the program and the collection and repayment of any amount paid m excess of the proper clatm amount which are found after momtormg or andmng by TDHS or the Umted States Department of Agriculture (USDA) This responslbdlty apphes to this contract, and all subcontracts hereunder C The contractor will apply to TDH$ for approval of changes to its original apphcatton and for prior anthor~zation for field trips tf meals served on the field tr~ps will be ¢la~med for reimbursement Requests for changes and field tr~p authortzation must be received by TDH$ at least five (S) calendar days before the requested effective date for the change or the field tr~p Contractors wdl not~fy TDH$ w~thm five (5) days of the terminatzon of an approved food service site 11I SFSP RECORD ](I~.I~.PlNG A The contractor will keep financsal and supporting documents, statistical records, and any other records pertaining to the servtces for which a claim is submitted The records and documents wall be kept for at least three (3) years and ntnety (90) days after the terminaUon of the contract period If any Imgation, claim, or audit ~nvolvmg these records begins before the stipulated time period expires, the contractor will keep the records and documents for not less than three (3) years and ninety (90) days af~er the termination of the contract perzod and untd all ht~gat~on, claims or audit fmdzngs are resolved The case ~s considered resolved when a final order Is issued in litigation or a written agreement is signed by TDH$ and the contractor Extensions are ¢onssdered as separate contract periods B The contractor and Its subcontractors wall allow TDH$ and USDA officials and other appropriate officials deternuned by TDHS to respect facilities and records and to audit, examine, and copy records at any reasonable time This mcindes access to all records of costs paid, even m part, by TDH$ Nee ~ Sponsors - Page 2 IV. CIVIL RIGHTS POLICY COMPLIANCE A The contractor agrees to comply with Title VI of the Civil Rights Act of 1964 (Public Law 8g-352), and all requirements imposed by the regulations of the Department of Agriculture CFR, Parts 15, 1ha and 15b) Department of Justice (28 CFR, Paris 42 and 50) and USDA and TDHS directives or regulations issued pursuant to that Act or the regulations, Section :564 of the Rehabilitation Act of 1973 (Public Law 93-112), The Americans with Disabdlues Act of 1990 (Public Law 101-336), and all amendments to each, and all requirements imposed by the regulations issued pursuant to these acts In addition, the contractor agrees to comply with Title 40, Chapter 73, of the Texas AdmmistraUve-Code These provide in pail that no persons in the Untied States shall, on the grounds of race, color, national origin, sex, age, disability, political beliefs or religion be excluded trom panic~pauon in, or denied, any aid, care, service or other benefits provided by federal and/or state funding, or otherwise be subJeCted to discrimination under any program or activity for which the contractor receives federal financial assistance from TDHS and USDA and hereby gives assurance that it will immediately take any measures necessary to effectuate this agreement B The contractor agrees to comply with Texas Revised Civil Statutes Article 4419b--4, Sections 5 03 and 5 04 (relating to workplace and confidentiality guidelines regarding AIDS and HIV) C This assurance is given in consideration of and for the purpose of obtaining any and all federal financial assistance, grants and loans of federal fund, reimbursable expenditures, grant or donation of federal property or interest in such property, the detail of federal personnel, the sale and lease of, and the permission to use, federal property or interest in such property or the furmshlng of services without consideration or at a nominal consideration, or at a consideration which is reduced for the purpose of assisting the recipient, or in recognition of the public interest to be served by such sale, lease or furnishing of services to the recipient, oi any improvements made with federal financial assistance extended to the contractor by TDHS This includes any federal agreement, arrangement, or other contract which has as one of its purposes the provmion of assistance such as food, cash assistance for the purchase of food, rental of food service equipment or any other financial assistance extended in reliance oh the representation and agreements made in this assurance D This assurance is binding on the contractor, lt~ successors, transferees, and assignees es long as it receives assistance or retains possession of any assistance from TDHS or USDA The person whose signatur~ appears on this contract is authorized To make this assurance on behalf of the contractor TDHS CLAIMS PAYMENT TDHS will, subject to the federal appropriation and availabdlty to TDHS of sufficient funds for the SFSP, make program payments to the contractor in accordance with the terms of this contract No reimbursement shall be made for performance under thl~ contract occurring prior to (a) the beginning effective date of this contract or (b) a later date established by TDH$ based on the date of receipt of a fully executed copy of this contract Non School Sponsors - Page 3 VI CERTIFICATIONS A Immigratton Reform and Control Act of 1986 - The contractor agrees to comply with the requirements of the Immigrat,on Reform and Control Act of 1986 regarding employment verlficat,on and retention of verification forms for any individuals hired after November 6, 1986, who will perform any labor or services under this contract B Regarding Debarment, Suspensaon, Inelagabllaty, or Voluntarily Exclusion For Covered Contracts - The contractor certafies, by execution of this agreement, that nmthec it nor its prmcapals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from part,cipatmg in thts contract by any federal department or agency or by the State of Texas By making th~a ceruficatlon the contractor agrees to the following terff~ 1 The above certafication is a maternal representation of fact upon which reliance was placed when this contract was entered into If it is later determined that the contractor knowingly rendered an erroneous certlficataon, in addition to other remedies avadable to the federal government, the Department of Health and Human Services, United States Department of Agraculture or other federal department or agency, or the Texas Department of Human Services may pursue available remedies, including suspensson and/or debarment 2 The contractor shall provide immediate written notice to the person to which thru certification as submitted if at any ttme the contractor learns that the certification was erroneous when submitted or has become erroneous by reason of changed c~rcumstances 3 The words "covered comract," 'debarred,' 'suspended,' 'meligthle," 'participant,' "person," "principal," "proposal," and "voluntarily excluded," as used in th~s certification have meanings based upon matermls in the Definitions and Coverage secttons of federal rules implementing Executive Order 12549 Usage ia as defined m the attachment 4 The contractor agrees by submattmg this cemficauon that, should the proposed covered contract be entered auto, at shall not knowingly enter into any subcontract with a person who is debarred, suspended, declared mel,glble, or voluntarily excluded from part~clpatmn m this covered transaction, unless author,-ed by the Department of Health and Human Serv~cas, Umted States Department of Agriculture or other federal department or agency, end/or the Texas Department of Human Servsces, as applicable 5 The contractor further agrees by submitting this certification that it will include TDHS Form 2046 titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts" without modification, m all covered subcontracts and m sohcitataons for all covered subcontracts 6 A contractor may rely upon a cerUfication of a subcontractor that Is not debarred, suspended, mehglble, or voluntarily excluded from the covered contract, unless it knows that the certtfication is erroneous A contractor must, at a minimum, obtatn certifications fresh tts covered subcontractors upon each subcontract*s Lmtlation and upon each renewal Non School Sponsors - Page 4 CERTIFICATIONS (continued) 7 Nothing contained in all the foregoing shall he construed to require establishment of a system of records in order to render in good faith the certification required by this certification document The knowledg~ and information of a contractor is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings 8 Except for contracts authorized under paragraph 4 of these terms, ~f a contractor in a covered contract knowingly enters Into a covered subcontract with a person who is suspended, debarred, mehglble, or voluntarily excluded from participation in this transaction, in addition m other remedies available to the federal government, Department of Health and Human Services, Umted States Department of Agriculture, or other federal department or agency, as applicable, and/or the Texas Department of Human Services may pursue available remedies, including suspension and/or debarment C Regarding Federal Lobbying - This certification applies only to this contract and is a material representation of fact upon which reliance wes placed when this transaction wes made or entered into Submission of this certification is a prerequisite for making or entering into this transaction LmpOSed by section 1352, title 31, U S Code Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure The contractor certifies, to the best of his or her knowledge and belief, that 1 No federally appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for mfluent, mg or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement 2 If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer employee of any agency, a member of congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federally funded contract, subcontract, subgrant, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, 'Disclosure Form to Report Lobbying,~ in accordance with its instructions 3 The contractor shall require that the language of this certification be included in the award documents for all covered subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all covered subreciplants shall certify and disclose accordingly The contractor certifies that all information submitted pursuant to th~s agreement la true and correct The contractor understands that the deliberate misrepresentation or withholding of information is a violation of this contract and may result In prosecution under applicable state and federal statutes Non School Spoosor8 - Page VII Eiq~'ECTIVE DATE AND SIGNATUILES For the faithful performance of the terms of th,s contract, the part,es hereto ,n the,r capacit,es stated, affix their signatures and bind themselves City of Denton Name of the Contract,rig Organff. aUon (Please Print or Type) Original mgnamre of the authorized representat,ve of the enntract,ng orgenu:auon Rick Svehla Name of the author,~ed representative of the contracting organn, ation (Please Print or Type) Acting City Manager Title Please print or UA)e, tn the spaces provided above, the name and Ude of the aut~ori-ed representative signing this agreement on behalf of the contracung orgamzauon TEXAS DEPARTMENT OF HUMAN SERV CES '~ '~ ~ z f'~ ~ Effective Dates through By Date Revised February 1994 Non ~ho~ S~ - Pa{~ 6 1996 CONTRACT YEAR of Human Serv~ms SPECIAL NUTRITION PROGRAMS SINGLE AUDIT IDENTIFICATION DATA c~tmcmf Name Kathy Mosby City of Denton N~:lre~s (elmer or P 0 ~Y. CiP/, Slate ZIP) 321 E McKinney Denton, Texas 76201 Te~none No 17560005146013 C~.,~,~,.~ No (817 ) 566-8125 Type pt [] For Proflt [] Non Profit [] Govemmentsl 09/30/96 Check the appropriate box(es) to Indicate the type(s) of program(s) In which you currently participate or for which you are applyin I COMMOOrTY ASSlS'rANC; pRO~RAMS CASH REIMBURSEMENT PROGRAMS [] A - National School Lunch [:~ AD - Adult Day Care I [::] B - Charitable Institutions [~ BL- Nation. School Lunch/Breakfast [~ C - Area Agency on Aging CC CACFP Center [~ G - Summer Camps [] DH - CACFP Day Home ~ H - Summer Food Sewlce [~ SF- Summer Food [] J - Jails ~ K - Soup Kitchen TE TEFAP [] I - TEFAP Commodit~es 9~llv~ mR [oi~[iGi~ ~lllU amount of ant federal financial =_$'d'~ts~nce that you agency receives other than from those programs listed above See attached ~--'IsINGLE AUDIT F. XEMP'rION-I ce~afy that I am not required to submit an audit under the S~ngle Audit Act for the following reason(g) I r-1, am a for-profit organization nll recaivc lee' than $2ti,000 'nnuaflY In t°tai federal funding ~IsINGLE AUDIT ASSURANCE-I understand that ~f I meet the requ;rements of the Single Aud;t Act. I will agree to submit [] An Annual [] A Biennial audLt as a condlaon of elig~b~hty to parbctpato ~n the Special Nutrition Programs, and that failure to do so ~s reClu~rod could result m adverse action. ,nclud~ng the w~thhold~ng of my cimm for reimbursement payments and termination of my contract. I also understand that If 1 am a pnvete non profit orgamzabon SUbleCt to the requirements of the Single Audit .- have a flnanaal audit pedormed annually, I must also obtmn a angle audit on an annual has= Name Lmea*e ~ge m prim) Rick Sveh:].a Acting City Mane§er FOil11 4SOe CERTIFICATE OF AUTHORITY This Is to aartlfy that Is daslanutacl as the authorized mpreaantotlva of City of Denton 321 E McKinney Denton, Texas 76201 The mpreeer~tutlve dealgnuted above 18 authorized on heheff of the ~ommotlng organization to make wdtton ants with the Texas Depemment of Human 8ervioea to operate a food program, to sign documents or reperto ~bout the agreement, and to pre~ent ~1/?~ ~lmbumem~, wh~. n~pproprl~te, to the department Rick Svehla Acting City Manager j~t. NoFOR DEPARTMENT~ OF _~_~ ~.A. Ni~BySERVICES USE ONLY. CERTIFICATE OF AUTHORITY This is to certify that Teresa Mil~ ].~im~ra S~rvJces M~na~r I Is designated as the authorized representative of ~of~emm~O~m~ City of Denton ~($~ ¢~v ~me ~P) 321 E McKinney Denton. Texas 76201 wRh ~ Te~ ~nt of Munn ~ ~ ~ · !~ ~, ~ M~n ~ or m~ ~ ~, ~nd to p~ ~i~ to~ mi~u~ment, w~n ~pp~e, ~ ~ de~me~ R$ck Svehla Act~n~ CSt~ ~ana[er . I'N~w"' ~FOR ~.~'~ *...."TMENT, OF H ~ ¥..~-N ~ew~ BySEl~n~'-~ USE ONlY of Huntln ~m4~ Ju~ CERTIFICATE OF AUTHORITY This Is to certify that IName of Auth~z~ O~c~] (;Xeue type o~ print) Title Kyle Hogue Summer Food Coordinator Is designated as the authorized representative of Name of Contracting Org~mzal~m I City of Denton A(~re~ (SIr~l City State ZiP) 321 E McKinney Denton, TX 76201 The representative designated above la authorized on behalf of the contracting organization to make written agree- ments with the Texas Department of Human Sem~loss to operate s food program, to sign documents or reports about the agreement, and to present claims for reimbursement, when appropriate, to the department Acting City ManagerI , FOR DEPARTMENT OF HUMAN SERVICE8 USE ONLY CERTIFICATE OF AUTHORITY This la to certify that I Mark Shipman Recraation Specialist I Is deelgnated e8 the authorized representative of City of Denton lA,dress (Street City 81ate ZiP) 321 E McKinney Denton,TX 76201 The representative designated above Is authorized on behalf of the contracting organization to make written agree- ments with the Tex~ Department of Human Services to operate a food program, to sign documents or reports about the agreement, end to preeent olelme for reimbursement, when appropriate, to the department ~]~ture--Offtci~l o! Co~t~act~ng Agency Date I Rick Svehla ~ctzng City ~anager , FOR DEPARTMENT OF HUMAN SERVICES USE ONLY Agr~lm. NO I~By Date I CERTIFICATE OF AUTHORITY This Is to certify that Nicole Henderson Children's Programs Supervisor Is deslgnatnd ss the sutber~zed repre"entstlve of City of Denton 321 E McKinney Denton, TX 76201 The rapre"entatlve designated ~bove la authortzecl on behalf of the contracting organization to make written agree- menu with the Texas Department of Human Saw,cee to operate a food program, to sign ckmumente or relxxt$ -.bout the agreement, and to pre~ent claims for reimbursement, when spprophate, to the department Rick Svehla Acting City Manager FOR DEPARTMENT OF HUMAN SERVICES USE ONLY From th~uQh APPOINTMENT OF THE AUTHORIZED REpR~ENTATIVE~The official who signs this fo~ must appoint an author~ represents five The official mw name himself as the authorlz~ ~epre8efltaUve, [f he chooses to sewe In ~h~ capacl~ The a~horized re,rosen tatve is given ~11 resp~fls bill~ for all ~SOA-donated commodltl~, and the maintenance of ali r~uir~ records and repo~s pe~ainlng to the commodities N~e of Aum~d Re~e ~O ~fle ~ele~fle NO i codify that I have reed the agreement on the back of this fo~ and that my signature below acknowledges this agency's respons~b~l iW to comply with ~11 of the terms and conditions of that agreement This agreement shall be In effect for no longer than one year It may be ~ended at both pa~les' option for ~o additional one-yea~ periods If exte~ed, the .ppllc=nt must update all pe~lnent lnfom.tlon and must demo~trate that all donated food received durin~ the prior contract period h~ been account~ for The agreement may be te~lnated for cause by either pa~ u~n 30 days wdtter notice The official who signs th{s Application and Agreement ~sumes full respansibill~ for compliance with the terms and cond~tions I~st ed ~n the agreement TO BE COMPLETED BY DHS JUNe JULY AUGUST ' SERVICE Meals, Meals Meals Dally To Be Served INFORMATION WUl B~ Dally To Be Served Dally To Be Served win Be Breakfast AM Supplement Lunch PM Supplement Supper From To AGREE,'vlENT THE APPLICANT FOR USDA-DONATED COMMODITIES AGRE~=S 1 To ab~de by the ~nstruct~ons and regulanons ~ssued by DHS and USDA for storing, handhng, and using commodities 2 To use commod~tlss only to benefit people sewed in the applicant's ests~ishel~food services operation 3 To request and accept commodities only m amounts that will be properly stored and fully utilized 4. To not sell trade, or d~spose of comrnod~tlee, ~ncludmg commercial processing of commod~e$ ~nto dn'ferent end products, w~thout DHS' approval 5 To provide adequate facflltfas and personnel to handle, store, protect, and use commodities 6 To allow DHS and USDA to respect, at any reasonable t~me, the commod~tise ~n storage and the fac~llbes used for han- dhng and storing commodities 7 To pay the assessments lewed by DHS to meet the admm~strative expenses of the program se prov~dod by state law 8 To accurately maintain ail necessary records, ~ncludmg the application and agreement forms, receipts and fraught b~lls, not~css of availability, arrNal and ~ssuance of donated foods, Forms 506, ~nventory control sheets, financial and support- ~ng documents, statistical records, and any other records pertinent to the services for which a cfa~m was submitted, for 3 years and 90 days after the contract period ended, or for 3 years after the end of the federal fiscal year ~n which services were provided if th~s contract has no specific termination date If any htJgat~on, cfa~m or audit involving these records be- gins before the 3 year penod expires, the contractor must keep the records for not less than 3 years and 90 days and until all hbgatlon, claims or audit findings are rssoived The case ~s cons~derad resolved when there ~s a final order ~seued in litigation, or when DHS and the contractor enter ~nto a wr~en agreement The contractor will keep records of non- expandable property acquired under the contract for 3 years after the final d~spos~bon of the property Contract period means the beg~nmng date through the ending date specified ~n the or~gmal agreement/contract, extensions are consi- dered to be separate contract periods 9 To comply w~th the requirements of the Immigration Reform and Control Act of 1986 regarding employment venficet~on and retsnt~on of verification forms for any md~wduals h~red after November 6, 1986, who w~ll perform any labor or services under th~s contract 10 To comply w~h the ~nstruct~oos and regulat~ans issued by DHS for conducting financial and comphance audits 11 To reimburse DHS, according to HS procedures, for any ~mproper d~stnbut~on or use of donated food, or for any loss D ' of, or damage to, donated foods caused by the applicant's fault or negligence 12 That any m~suse of donated fc~ds may cause them to be disqualified from program partlc~pation, and that reinstatement = at DHS' option 13 That any embezzlement, misuse, theft, or obtainment by fraud of donated foods or donated food-related funds, assets, or property, shall cause the applmant to be Sublect to Federal criminal prosecution 14 C~vll R~ghts (a) To comply w~th Title VI of the Clwl R~ghts Act of 1964 (Public Law 88-352), Section 504 of the Rehab~htatlon Act of 1973 (Public Law 93.112), The Americans w~h D~sab~hbos Act of 1990 (Public Law 101-336), and all amendments Io each, and all requirements imposed by the regulations ~ssued pursuant to these acts In addition, the contractor agrees to comply w~th Title 40, Chapter 73, of the Texas Administrative Code These provide m part that no persons ~n the Umted States shall, on the grounds of race, color, national orlgm, sex, age, d~sab~l~ty, political behefs or religion be excluded from participation in, or darned, any aid, care, service or other benefits provided by federal and/or state funding, or otherwise be subjected to d~scnmlnat~on (b) To comply w~th Texas Revised Clwl Statutes Article 4419b-4, Sections 5 03 and 5 04 (relating to workplace and con- fldentlahty gu~dehnes regarding AIDS and HI~ (c) To compile date, maintain records, and submit reports as required, to permit eftect~ve enforcement of the above Acts and permit author,~,ed DHS and USDA pemonner dunng normal worl~ng hours to revrew such records, books and accounts as needed to ascertain compliance w~th the above Acts If there are any violations of this assurance, DHS and USDA have the nght to seek judicial enforcement of this assurance Th~s assurance is binding on the Contractor, rte successors transferees, and assignees as ~ong as ~t receives easlstance, or retslns possession of any assistance from DHS The person whose s~gnature appears on th~s contract is authonzod to s~gn th~s assurance on the behalf of the Contractor The above assurances are 91yen in consideration of and for the purpose of obtaining any and all federal flllanclal ~sn~stancs, grants and loans of federal funds, reimbursable expenditures, grant or donation of federal property and interest property, the detail of federal personnel the sale and lease of, and the permission to use, federal property or interest in such property or the furmshmg of services w~hout consideration or at a nominal consideration, or at a consideration which ~s reduced for the purposes of ase~stmg the recipient, or In recognition of the pubhc Interest to be served by such sale, lease, or furmshlng of services to the recipient, or any Improvements made w~th federal financial assistance extend- ed to the program applicant by DHS Th~s includes any federal agreement, arrangement, or other contract which has as one of ~ts purposes the prows=on of cash as.~stance extended ~n reliance of the representabon and agreements made ~n this assurance Form 47~2 ~ .,m~ s,~mJ NONGOVERNMENTAL CONTRACTOR CERTIFICATION ~'he Texas Department of Human Services (DHS) has adopted rules pertaining to controctlng with organizations in which · former board member or employee (whose last day of duty was within the past two years) has any ownership or control, or who ia an employee or consultant of such orpanlzaflon Alas, Human Reeoumss Code ~.2 0033 prohibits for one year after employment former DHS employees in pay grades equivalent to or above pay grade 17, Step 1, from helping (for pay) another entity obtain a contract with DHS In an ares for which the former employee was directly concerned or had administrative responsibility Addltlonatiy, DHS has adopted standards for oontrsotlng with contractors associated with current or former employees and board members, end their rsiaflvee This form is neeeessry to help the Department determine compliance with those rules All potential non-governmental contractors for any type of oontrsof must complete this cartlflceUon The contract, If swarded, may be terminated for nauee If (1) the contractor knowingly provides Inaorroot Information In It~ oertlfloatfun, or (2) the oontrsofor uses · subterfuge, such ss · subcontract errsngemmlt, to avoid the application of state laws or DHS roles Does the potential contractor have ss en officer, dlroofor, employee, consultant, or owner (in whole or In pa~t) 1 A person who is =urrsnUy a DHS employee or DHS board member, [] Yes [] No 2 A parson who was · former DHS employee or board member whose iaat day of duty with DHS was within [--']Yes [~]No 3 A persoc who is related (see Reiatmnship key below) to ·eurrsnt DHS employee or DHS board member? ~"~Yes [] No 4 A person who ia related (see Relationship key below) to a former DHS employee or DHS board member ['-]Yes [~No whose lest day of carvica to DHS was within the past two years? RELATIONSHIP Husband Siator Stepson Sp~uoc's Brother KEY Father Son Mother-in-law Mother Daughter Father4n-iaw IF YOU ANSWERED "YES" TO ANY OF THE ABOVE QUESTIONS, YOU MUST COMPLETE FORM 4732-A. CERllFICATION I cartlty that the Infommtian above la complete, true end ocrrsat to the best of my knowledge I understand that lask of full, tam and cemplofe dl.olssum may be grounds for withholding payment for delivered ssrvloss and may cause contact termlcefloc FORM 4732-A Instn~ct,on$ NONGOVERNMENTAl. CONTRACTOR CERTIFICATION (Part II) PURPOSE Number of Copies l;orm 4732-A; Nonl;overnmental Contractor Ceil- Complete a certification for each copy of the ficauon, Pan II, provides a means for collecting contract offer/contract renewal submitted to thc and dlstrthutmg additional needed reformation department about nongovernmental potential contractors who mark "yes" to any of the questions on Form 4732, Trarmmfftal Nongovernmental Contractor Cert;ficatmn Incorrect or incomplete information may render a Forward the appropriate number of certifications contract unpayable or cause termination The tn- m the department's procurement officer (for new fomutlon is tlsed to determine whether a contract/ contracts) or contract manager (for contract contract reneWal can by state law and Department renewals) Form 4732-A is attached to Form 4732 of Human Services' rules be consununated and Is submitted as part of the offeror's ~ procurement package or as Indicated in the instructions to the procurement package In cases PROCEDURE of contract renewals, the Form 4732-A is submitted as an attachment to Form 4732 to the Potential contractors answering "yes" to any of the contract manager approximately 60 days prior to questions on Form 4732, Nongovernmental effective date of any proposed renewal Contractor Certification, must complete the additional questions and thc certification m Form Fo~m Retentmn 4732-A Forn~ 4732-A ts prepared along with Form 4732 It is signed by the person signing Consistent with the records retention rule, §69 205 Form 4732, and ts submitted as an attachment to and related policies found in Item 2100 of the Form 4732 , Contract Admtntrtratton Handbook, thc successful contractor's Form 4732-A must be kept for three When to Prepare years and 90 days after the comract period ends or until all litigation, claims, or audit f'mdmgs are Form 4732-A] must be prepared and submitted as resolved, whichever is longer Unsuccessful an attachment to Form 4732 It is sam to the area offerors' l;orm. 4732-A must be kept a mlmmum purchasing the contract prior m consummating a of slx months after the effective date of thc new contract or a contract renewal It must be comract or until the resolution of any appeal or submitted early enough (usually 60 days prior to litigation resulting from the procurement, the contract*si effective date) so that the purchasmg whichever is longer area can provide it to the department's Office of thc General ~onosel 45 days prior to the contract's effective date If thc contract is a new procurement, rather than a renewal, thc certification is submitted according to instructions m the request for proposal Texas Dapt of Protective and Regulatory Services APg 94-6 Texas Dept of Human Services AMH 94-14 CAH 94-6 CACFP-ADC 94-7 NSLP/SBP 94-6 CACFP-CCC 94-7 PHC 94-9 CACFP-DCH 94-7 SFSP 94-6 SMP 94*5 Instructions Form 4732-A Page 2 DETAILED INSTRUCTIONS 2 Did you answer "yes" ?-- Self-explanatory Name of Person Associated with P~tentie/ I Did you answer "yes". ? -- Self-explenato;7 Contractor- Enter the name(s) of officers, Name of Person Associated w~th Potential directors, employees, consuinmts, or owners Contractor -- Enter the names of officers, (m whole or part) of the potential contractor directors, employees, consultants, or owners who are related in the following manner (I) to (m whole or part) of the potential contractor current DHS employees or board members, or who (1) are currently DH$ employee~ or DH$ (:2) to persons who are former DHS employees board members, or (2) are former DH$ or board members on or after Septamber 19877 employees or board members whose lest day A Wife H Daughter of duty was within the pest two years B Husband I Stepdaughter Lost/Current Positson Held ot DHS -- If the person wes/is employed with DHS, use the C Father J Stepson person's DHS job title E~mmple: 'Clerk D Mother K Mother-in-law Typmt H" rather than 'Secretary" Use a descriptive title only if the job title is E Brother L Father-m-law unavailable F Sister M Spouse's Seer Be§m Date at DHS/Ending Date -- The G Son N Spouse's Brother person may have held more than one posinon with DHS Enter the person's last period of Current Position with Potential Contractor association with DHS If thc person is still -- Enter the person's current title with the associated with DH$. enter the beginning date potential contractor to the 'present" Program/Support Area of DH$ -- Enter the Beginning Dote -- The person may have heed name of thc DHS program or support area m positions other than the present one with the which the person worked. If the person dealt potentml contractor Enter the person's first directly with the potential contract, so date of association during which tune the Indicate. person has been continuously aesocmted with Current Position with Potential Contractor the potential contractor to the present time -- Enter the person's current .job title with the Name of Cummt/ForrnerDHSr:mployee/ potential contractor Emtmples. owner, board ~nam* Mem~be~ -- Eater the name of the member, intake worker person's relative who is essocmed with DHS Begmnm.~ Date -- The person may have heed positions other than the present one with the ReletionefOp to Pers~ A##ociotod with potential contractor Enter the person's first Potontio/Cont~aotor -- Seef-explanator7 date of association during which time the person has been continuously associated with the potential contractor to the present tune 25% or Mo~e Incrsase in Compensation -- If as result of discontinuing employment with DHS and by commencmg assocmtlon with the Texas Dapt of Protective potentml contractmg agency the person and Regulatory Services recewes a 25~ or more increase m overall APS 93-4 annual benefits, including salary or wages, Texas Dept of Human Services enter 'yes ' If not, enter "no" AMH 93-6 CAH 93-9 CACFP-ADC 93-5 NSLPISBP 93-3 CACFP-CCC 93-4 PHC 93-7 CACFP-DCH 93*4 SFSP 93-4 SMP 93-2 Instructions Form 4732-A Page 3 Last/Current Position Held at DH$ -- If the Certlhcatlon -- The certification at the person was/is employed by DHS, use th~ bottom of the page applies to all reformation person's DHS job title Evnmple: '~Clerk provided on the certification form Typist I[" rather than "Secretary. Use a Name of Potential Nongovernmental descriptive title only if the job title ts Contractor -- Give thc cntlty'$ official name unavailable If the entity ts registered with the Texas Program/Support Area at DH$ -- Enter the Secretary of State, type or legibly print the name of the DHS program or support area m name as regtstcred with the Secretary of State which the person worked If the person1 dealt Contact No -- If the cemficaUon ts threctly with the potenttal contract, so tndtcate prepared as pan of a procurement package, Begin Date at DHS/Endlng Date -- Over a leave flus space blank If the eemficatton ts conttnuous penod of tune, the person may prepared durtng the renewal of a contract, have held more than one position with DHS emer the contract number If avatlable, use the Enter the person's last pertod of assoctauon DHS uniform contract number wtth DHS If the person ts mil assoctated with $ocla/Security No or VIN -- If the DHS, enter the begtnmng date to the potential contractor has a vendor tdenttficatlon "present" number (VIN) from the State Comptroller's Office, enter that number, otherwtse, the Prah/b/t/ons Age/nsf Contracts w/th person authonzed to stgn the cemficauon Certain Fourier Employees -- enters his Social Secunty Number (SSN) A If "no" ts checked, skip to number 4 If Description of Contracted Se~v/ce//tam -- 'yes" ts checked, continue Enter a descnpUon of the servtce or ttem to be B - D Self-explanatory purchased under the contract ~'.,~nmples. cluld E If the employee earned a salary equtvalent day care, medtcal traneportatton, family care, to, or more than, a Group 17, Step 1, of the computer software, jamtonel services posit~on clesstficauon salary schedule Signature of Authorized Representative/ (currently $30,588) enter "yes" If not, enter Date -- Self-explanatory "no" Pnnt or Type Name -- Prat or type the name of the signatory Financial Interact -- Name -- Self. explanatory Owns 10% er More -- Ifa former DHS employee, former board member, or their relatives (as specified tn question 3 or 4 of Form 4?32) owns or controls 10% or more of the contracting firm or its stock, enter "yes" If not, enter "no" ~2.500 or More Investment -- If a former DHS employee, former board member, or theft relatives (as apectt-ted tn question 3 or 4 Texas Dept of Protective of Form 4'/32) have afl mvesl~ent of $2,500 end Regulatory Services or more m the enntractmg agency, enter APg 94-6 "yes" If Iici, e~er "no" Texas Dapt of Human Services AMH 94-14 CAH 94-6 CACFP-ADC 94-'/ NSLP/SBP 94-6 CACFP-CCC 94-'/ PHC 94-9 CACFP-DCH 94-7 SFSP 94-6 SMP 94-5 Texas D~pmlmenl ot H.m~ ~r,~. NONGOVERNMENTAL CO~OR CERTIFICATION (PART II) A ~ a ~ndlUon for receding ~ ~ntra~ or ~lng · ~ntract renewed, ~tentlal ~ntrsctors w~ answer~ "yes" to either or both of the questions on FO~ 47~ mum ~mplete the ~ue~tlo~ on this fo~ ~o~ 4~2-A) The questions must be futly answered ~ the cedlflcatlon on Page 2 must ~ ~mpleted and signed The snswem are used to dete~ine ~mpll~nce with Tex~ Depa~- ment of Human Sewlces rules fou~ In the Te~s Adm. ~de, Title 40, C~pter 79, ~79 1~01.79 1807 1 REGARDING P~ AND CURRENT DHS EMPLOYES AND BO~D MEMBER~ D~d ~ an~r "~s" to qu~n 1 or 2 on Fo~ 47~? ~Yes ~No If "~," skip to qu~tion 2 If "y~,' ~mpiete the following Info~ion for t~e ~ If thw are FORMER DHS emp~yees, I~lcate ~ether ~cl~t~n with the ~tenflal ~m~r m~ult~ In a 25~ or ~re Inc~e In ~erall ~nnual benef~e (including ~) over ~at w~ recel~ ~en the i with DHS. 2 REGARDING ~0~ ~iA~D ~ ~ ~~ ~D ~E ~A~' D~ ~ an~r "~" ~ q~n 3 or 4 on ~ 4~ "~,' 8~p ~ q~i~q 3 ff "yM," ~e~ ~ Ml~wlng I~Mn Mr t~M ~m~ ~ hit ~Mtl~l 3 Prohibitions Against Contracts with Cert=~n Fo~rnar Employees A Has the potential contractor and/or any of hm employees been employed by DHS within the laot 12 months? r-'] Yes [] No If "No," skip to number 4 B Is s former employee, or an orgsmzat~on controllsd (~n part or whois) by a former employes, appyng for this contract? [] Yes [] No C Has (or will) the former employee(s) be prod to aid ~n the development of or the attempt to obtain the proposed contract? []Yes []No D Does the propnsed contract relate to · program or esrvK:e m which the potenlial contractor/employee(s) (while with DHS) was directly concerned or had admlntstratwe responsibility? []Yes []No If "No," Iklp to number 4) E If the answer is "Yes" to "B' and 'D," or 'C" and "D," provide the former DHS employee's name and Indloete whether he earned an annualized WGii 8slaty of $30.588 or more ,mt the hms he left employment with DHS NAME I~0,m or mom? DY- I-'IN. 4 Financial Interaot--ProvKli the name and other requested intommtlon about any hereon who is owner (in part or whole), officer, director, employee, or consultant employed or associated with your organization and who A. wes '' member of the DHS Board -,nd v/no left within the past two years, B ts cow ''rnsmber of the DHS Boa~, C was an employee of DHS ''nd who loll within the pest two yearn, Dle now an empfoyee et DHS, or E ts related in a mannsr specified In Question 3 or 4 of From 4732 to the pemen(8) lo lleme A, B, C, 0~, D immed/toly above DY. DNo r"'ly# I-'ly# DNo r"ly# I-1y# CERTIFICATION I certify that the above Informetlon lo complete, true end correct to the best of my knowledge. I ulxleratand thet lick Of full, true and complete dinctosure may be ground~ for withholding payment for delivered 8ewlese ''nd toby couee ~omra~t temdfl~tlift. '---- --'"1 ***NOTICE*** The 1996 Summer Food Service Program is sponsored by the City of Denton, Parks and Recreation Department, and is offered through a federal grant which requires that sponsors apply each year to retain eligibility to offer the program. It is therefore, our declaration that the SFSP will be offered this summer, from May 28th through August 9th, strictly as a PILOT PROGRAM, and that the City of Denton PARD, is in no way directly liable or responsible for the continuance of the program in the future. ~MI~R FOOD ~ I~OORAM p~eonn~ Staff ~e H~ T~ ~2~ 1 112 91 08 tl 266 18 ~ ~ ~3 113 18 ~1 ~A ~ 0 0706 ~ ~2~ lC ~ 0 0234 ~ ~72 86 ~ ~ 408 87 T~ ~ T~ **Difference of $1.85 is due to roum~ing Hum. S.r~. SUMMER FOOD SERVICE PROGRAM FOR CHILDREN CIVIL RIGHTS QUESTIONNAIRE CIVIL RIGHTS ACT OF 1964 A 1 Es.mate, by racial/ethnic group, the number of children that will participate In the program at each site If the progrem conmsts of several camp sessions, specify the projected number of children by site and date of Session SITE AMERICAN ALASKAN ASIAN/ pACIFI¢ BLACK HISPANIC WHITE (name of MIA, Iohoel, ramp, tlc ) INDIAN NATIVE 18t. ANOER Owsley Park 20 15 5 TWU Clubhouse Program 10 10 35 Denia Park 5]8 Phoenix Park Civic Center Park 10 10 20 MLK Recreation Center 60 20 10 Villa~ East A~ar~m~n~ 20 10 20 100 100 20 Rayzor Elementary School 25 100 25 Houston Elementary School 10 10 10 2 Deandbe how this projection was made (i ·, based on comperatwe enrollment In Eitco, oboervat~on of Etudants, student sumamas, otc Observation of neighborhoods B Does the organization have specific membemhip reqmrements which result in the denial of program benefits to specific groups? [] Ye8 [] No If yes, dsecnbe those requirements C Whateftorts~llbemede Wthe~rgan~za~ntoc~ntactmi~dgressr~=~;an;-~h~b~ut~e~po(X1un~participa~inthe~x~gmm? Posters displayed in neighborhoods, attend community meetings and public service announcements D What other outreach stop8 will be taken by the organization to ensure thet minonhas in the area from which It draw~ its attendance will have an equal oppartunity to participate ~n the program? S F S P. information will be printed in spanish E Has any federal agency notified the organization of non-complmnce wKh the Civ. I Rights act of 19647 [] Yes [] No If yes, give details including dates, names, and results II REHABILITATION AOT OF 1973 (Section 504) A Does the contracting organization have any policies, pracbcas, or architectural berners that limit, deny, or discourage participatmn in the program or employment by the contrashng organization because o! dis=hility? [] Yes [] No If yes, explain B Are there any policies or practices that result in unequal treatment in the pohvery of benefits or services to pamclpants, applicants, or employees according to disability? [] Yea [] No If Yes, explain C Does the contracting organizahon employ 15 or more people? [] Yea [] No If yes 1 Enter the name and title of the ccord~netor who will work with DH$ to ensure that -__q,~__!_-n 504 requirements are mst Teresa Mflam Leisure Services Manager I 2 Has the orgsnlzatlon established grievance procedures that incorporate appropriate due procas~ standards? [] Yea [] No If yas, do thase procedures provide for the prompt and equitable rasolution of complblflta that allege an action prohibited by Section 504 of the Rehabilitation Act of 10737 r'~yas E:]No 3 Has the contracting organization Informed the public of the right to file a complaint and of the filing procedure? [] Yes ~'] No If yes, briefly describe how tho pubhc was tnformed There are posters and flyers posted throughout the City of Denton which acknowledges the City's compliance with the guidelines set by the EEOC, ADA, and the Civil Rights Act These posters give instructions for filing a complaint D Has tho organlzaton taken stops to notify employees, bartictbants, and apphcants that the organization does not discriminate on the barns of dmability? [] Yes [] No If yas, do the people notified include tho~e with impaired vision or hearing and membem of unions or profemdonal organizations holding colioctwe bargaining or profes~ion81 agreements wrm the contra~lng organization? [] Yes [] No If yas, briefly de,mcriba how they ere notified The visually or hearing impaired are notified through radio and television advertisement Also flyers, announcements, etc. are mailed E Do all organization forms, publication, and recruitment matertals which fnform tho public of program benefits and employment opponunitlas contain the asauranco that the orgamzat~ondoes not d~dmthate on the baels of di88bl#ty? I'~ Yes [] NO If no, indicate steps being taken to comply with this requ,remem F Doas the organization have a procequre to ensure that the reined=al or corrective action has been or will be taken ff non-ocmplianco with non dtacrimioaiton requ,remenfs rs found by DHS. USDA. o~ tho contracting organization it~lf~ [] Yas [] No Ifyas. explaln If not handled within the department in question, the City gererally channels all complaints through the Legal Department PUBLIC SERVICE ANNOLrNCEMENT FORN -~SITES Fhe Denton Parks and ReereaUon Department announces the sponsorsbap of the 1996 Summer Food Semace Program Meals will be prowded at the rotes hsted People who are ehg~ble to pam¢lpate m the program must not be dmenrmnated against because of race, color, national origin, sex, age, d~sab,l,ty, rehg~on, or polmeal behef Anyone who beheves that they have been dmcnrmnated against should write mamedmtely to D~rector, C~wl Raghts D~vm~on, MC-106, Texas Department of Human Services, P O Box 149030, Austin, Texas 78714-9030 or the Secretary of Agriculture, Wasl~ngton, D C 20250 Note Dmcnmanat~on complaints based on rehg~on or pohueal behefs must be referred only to the D~rector, C~wl R~ghts D~vm~on, Texas Department of Human Semnces Dates S~tes Address T~me May 28-Aug 9 C~w¢ Center Park 321 E McI4hnney 12pm-lpm May 28-Aug 9 Dema Park 1001 Parvm 12pm-lpm May 28-Aug 9 MLK Rec Center 1300 Wilson 12pm-lpm May 28-Aug 9 Owsley Ne,ghborhood Stella St 12pm-lpm May 28-Aug 9 Phoemx Park 308 S Ruddell 12pm-lpm May 28-Aug 9 TWU Playhouse Program Mary Hufford Court 12pm-lpm May 28-Aug 9 Village East Apartments 1700 Village East 12pm-lpm PUBLIC SERVICE ANNOUNCEMENT FOR THE ~ SITE The Denton Parks and Recreation Department announces the sponsorstup of the 1996 Summer Food Service Program Income Ehg~b~hty vnll be based on fanuly size and income using the Standards for Detenmmn8 Free and Reduced-Price Ehg~bdity, provided by the Umted States Department of Agriculture Meals will be prowded at the site listed People who are ehglble to participate in the program must not be d~scrunmated against because of race, color, national origin, sex, age, disability, religion, or pohtlcal behef Anyone who believes that they have been dlscnrmnated against should write immediately to Director, Civil Paghts Division, MC-106, Texas Department of Human Services, P O Box 149030, Austin, Texas 78714-9030 or the Secretary of Agriculture, Washington, D C 20250 Note D~scnrmnat~on complaints based on rehg~on or political beliefs must be referred only to the Director, Clwl ~ghts Div~sion, Texas Department of Human Serwces Dates S~tes Address Time June 3-28 Houston Elementary 3100 Teasley Lane 11 45am-12 45pm June 3-28 Rayzor Elementary 1400 Malone 11 30am-12 30pm Form la06/Attlchmem B SUMMER FOOD SERVICE PROGRAM FOR CHILDREN Jlnulrv 1990 ADDITIONAL ASSURANCES FOR CAMPS AND OTHER ENROLLMENT PROGRAMS THAT CHARGE SEPARATELY FOR MEALS As required in Section V of this application, the contracting organization assures the Texas Department of Human Services that I The method of collecting meal payments will prota~t the anonymity of children who receive free meals 2 The organization has or will estabhsh · hearing procedure for famihas w,thmg to appeal a demi] of an application for free malls, which provides the following A Tbet elelmpiz, publicly announced methml will be used for a family to make an oral or written request for a hearing, B That the filmily will hive the opportunity to be ellisted Or represented by in Ittornay or other person, C That the family will have 8n opportunity t~ examine the documents end records supporting the dectsmn bemg appealed both before and during the hearing, D That the beefing will be reasonlbly prompt end convenient for the family, E Tbet adequate notice will be g~ven tu the family of the time and Piece of the bearmg, F That the flmily will have an opportunity to present oral or documentary evidence end arguments suoportmg its position G. This the fimlly will heva in opportunity to quest:on or refute iny testimony or other evidence end to confront and cross ex.mine Iny adverse witnenev, H Tbet the hearing will be conducted and the decision made by a hearing official who d~d not partielbete in the action being appealed, That the decision weft be bead on the do~umantery evideoce presented It the hearing lad made pitt of the record, J Tbet the family end any dev~gnetod ropretentetIva will be notified m writing of the decision. k Tbet · written record will be prepared for each hearing wh,ch includes the action being appealed iny documenter,/ eviderme lad · summery of oral testimony presented it the hecnng, the decision ind the recsuns for the decision, and · copy of the notice sent to the family, end L That the written record will be maintained for a period of three years .nd SO days following the conclusion of the beer- in., during which it will be available for exammatton by the family or its repreNntet~vas, end officials of the Texas Da bertment of Human Services (TDHS). the United States Department of Agriculture end other relevant officials es deter mined by TDHS at any reasonable time and pla;t 3 If a family requests a hearing, the chJld(ren) will continue to receive frae meals until I declSlOO IS rendered SUMMER FOOD SERVICE PROGRAM FOR CHILDREN Pace2 COLLECTION OF PAYMENT OPTIONS FOR PROGRAMS THAT CHARGE SEPARATELY FOR MEALS (Camps and Other Enrollment Programs Only) COLLECTION PROCEDURE 1) Each day, children =an buy tickets in the food service manager's office, but they do not receive the t~ckets The food sar vice manager sends the pumhamd tickets and tickets for free meal recipients to the site each day The site subervisor daltrlbutes the tichets jUlt before meal tlme The tickets are coded for Iccountlng puq~oms COLLECTION PROCEDURE 2 Each day, children pay for their mecls in an office A list with the nsmm of all children who paid or era ahgible for frec mecll I$ prepared and sent to the meal service area A staff member who know~ the ahildren cheeks the names es children pms through the line or otherwise receive their meal After the serviaa of the meal the list is re~Jrned to the office for ecouuntlng puq~oles This method works only In a smell site where the staff member knows all the children COLLECTION PROCEDURE 3 The site supervisor glVm ecah child an envelope for daily, weekly, session or monthly payments Children tatum the anval ep~ with the payments enclmad, or empty if eligible for frae meals The envelodm ere collected in the office end coded tiaketl are Issued to each child COLLECTION PROCEDURE 4 Pemotl pay in odvan=e by the month or ~esslon Each site superVlsur recewm a list of those children who have paid The site luRervllor masks the list m paid for children who receive frae meals Only the bookkeeper knows whivh Chlldlen ;eceiva a free meal The site supervisor keeps daily records of each Child served and sands the reaord! ~o the ofhce for ac counting puq)eces COLLECTION PROCEDURE S Mill payments are collected in the offtee Peymentl gan be mede by children or parents on e dally, weekly, session or monthly bmis The secretary records payments and knows which Children qualify for free meBis At the sites, the secretary dlstrilmtas identical tickets labeled only with the children's name Sin~e the parents may make pwments, even Children who receive frae meals may not know whether their mecJs era free or paid COLLECTION PROCEDURE 8 Plants are billed monthly or by lesion for paid meals their children are served Paints mall in all payments All paniaipn. ting children receive · coded richer aech month, which Is punched et each meal smvlea At the end of the month, the t~e kets ere oullected end e elmk aal~uivtes the Imouflt to be billed COLLECTION PROCEDURE ? Other Exploln in detail (attach · sheet If more space is required) The oontraator must ensure that this method prevents the overt Identification of ch.ldren receiving free meals SUPPLEMENTAL ATTACHEMENT TO ORDINANCE~NO.96-083 Changed pages are noted TEXAS DEPARTMENT OF HUMAN SERVICES Specml Nutrition Programs ~ A~'~, 3023 Bledsoe Street, SuiteD ~.~.}~ Fort Worth, Texas 76107-2950 ~~ PHONE (817) 870-2278 May 23, 1996 TX #061 1002 Mr Ted Benawdes, C~ty Manager Center of Denton 321 East Mck~nney Denton TX 76201 SUBJECT Summer Food Serwce Program (SFSP) Approval for Partm~pat~on FY96 Dear Mr Benawdes Your organization ~s approved to participate as a Sponsor m the Summer Food Service Program (SFSP) for Ftscal Year 1996 A fully approved Form 1506 and a SFSP Agreement with ong~nal s~gnatures of the authonzmg Contract Manager affixed are enclosed Also enclosed ara program operation forms The attached ~nformatlon table ~dentdms the program operatmn forms, the number of forms enclosed and general instructions for completion, submlssmn, or maintenance Specific ~nstructmns to the forms are contained In Sectmn 12 of the Summer Food Serwce Program Handbook w~th the exception of the Weekly Call-In Report Instructmns to the Weekly Call-In Report are attached to the forms enclosed You, as a Sponsor, are required to use the TDHS program operations forms enclosed w~th the exception of Form 1514, Claims for Reimbursement Worksheet, and SFSP Dady Meal Production Form The use of Form 1514 and the sample SFSP Dady Meal Production Form Is optional I recommend the use of Form 1514 for compdmg data to complete the clmm for rmmbursement Food servme personnel must document meal production each day The sample meal production form enclosed is offered for your use However, you may use another form of cholca that ~s an ~nformat~onal equivalent to the sample form All the program operation forms enclosed may be duphcated by program sponsors w~th the exception of NCR (carbonless) Forms 1513 and Form 1513-A Contact thru office ~f additional forms are needed Your orgamzatmn should maintain, as part of their official contract flies, cop~es of forms completed and forms submitted to TDHS Sponsors must comply with the requirements for form retention The requirements for forms retention are specdmd m the instructions for the form m the SFSP Handbook Please contact me at (817) 870 2278should you have questmns Sincerely, David J Clmre Area Program Manager Enclosures SUMMER FOOD SERVICE PROGRAM SERVICE AGREEMENT APPROVAL & PROGRAM OPERATION FORMS The Summer Food Service Program (SFSP) approval documents are the Apphcat~on for Participation, Form 1506 and the SFSP Agreement A fully approved Form 1506 and a SFSP Agreement w~th original s~gnatures of the authorizing contract manager afhxed are returned to you The attached mformat~on table ~dent~fms the program operation forms, the number of forms enclosed, and general ~nstruct~ons for completion, subm~ssmn, or maintenance Spec~hc mstructmns to the forms except the Weekly Call-In Report are contained m Section 12 of the SFSP Handbook Instructions to the Weekly Call-In Report are attached to the forms enclosed Sponsors are required to use the TDHS program operations forms enclosed Food serwce personnel must document meal production each day A sample form ~s offered to sponsors to document your orgamzat~on's meal productmn However, sponsors may use another form of choice that ~s an ~nformatmnal equwalent to the sample form that ~s enclosed The program operation forms enclosed may be duphcated by program sponsors w~th the exception of NCR(carbonless) Forms 1513 and Form 1513-A Contactthm ofhce ~f additional forms are needed Sponsors should maintain, as part of their official contract files, copras of forms submitted to TDHS Sponsors must comply w~th the requirements for form retention The requirements for forms retention are specified ~n the SFSP Handbook Your next S~ngle Audit Report for F~scal Year ~. ~s due /,~ JG-~ Sponsors should contact their Area Program Manager at the follow~r~' r~aihng address and telephone number should you have questions Dav,d J Claire Texas Department of Human Services Special Nutr,tion Programs 3023 Bledsoe, Su,te D, 128-2 Ft Worth, Texas 76107 of~rv~es SUMMER FOOD SERVICE PROGRAM Fort OHS STAFF ONLY APPLICATION FOR PARTICIPATION NO~ Give as m~ch Informstlon as ~lble A~ch ~dltional sheets If needed, ~ B~a~ut ~ A M Supp ~unch pleaseldentl~eacha~chmenlwl~thenameof~econtr.ctingo~anl~tlon ~PM Supp ~Sup~r ~AII SEC~ON ~SPONSOR INFORMA~ON 321 E. McKinne7 Denton, TX 7620~ Teresa Milam Services Manager A Con~a~or Class~fl~ (Che~ all ~at app.) ~ A~emlc Y~r National Unit of Govemment~tra~ ~es ~t ~1 f~ ~ Natlo~l Y~h S~ P~mm ~ Youth S~ P~mm ~ se~ s~es =e o~ra[~ d~r~y by ~e ~ba~= ~ Resldentlal~onmsldenflal Continuous ~le~ar B Is ~r program a year.round pr~ram? ~Yes ~ No C T~ ~ ~n~a~or ~ Publ~ En~ (e~&n) Is ~r a~ m~r~ to ~ sate ~at~? ~Yes ~No into Treuu .IA Y,= No ~s, m Rd~r~lt? ~Yea ~No ~P~ ~np~ ~an~Taxmxempt a~tus ~bl~ A~ ~er d ~ yes · ~ di~ ~ _ D ~s ~e ~an~ pm~de an ongoing year round se~m m ~e mmmun~ ~at · e Summer F~ Se~ Pr~ram (SFSP)? ~Yes ~No If ~, ~i~ of ~e foll~g ~r~ms~n~s apples? ~ R~n~l ~mp ~ Failure to o~mte w~ld deny p~mm to a ~r ~ ~s Migrant Children ~ Failure to o~mte would deny a s~nlfl~nt numar of chilton ~ss to pr~mm E 1 ~s ~ organlzaaon r~e $1~,~0 or m~e in f~eral funds yea~y? ~Yes ~No 2 ~s ~e ~gani~n ~ve more ~an $25,~ but less ~an $1~,~ m federal funds yes~ ~Yes ~ No 3 A~ a mW of ~e audit ~venng last yea~s pr~ram o~rat~on or d~menta~on ~at an audit ~nfo~mg ~ndu~ed. Including ~e date ~ will be ~ndu~ed ~ou must submit a completed Fo~ 1569, S~cla/Nutrition Programs - Single Audit Mentlf/catlon ~ta ) SECTION II-BUDGET A Estimate all SFSP costs which w~ll be cJa~med for reimbursement for the program year I P~OQflAM YEAR 2. PROGRAM YEAR ESTIMA'I~D OPERATIONAL CO~TS COST~ ESTIMATED &DMINI~'rR&TIV~ COSTS COST~ Administrative Labor Program Labor /~, 225 (Management Men,tot Clenca]) Fringe Benefits 422 Fnnge Benefits 3 ! ]. Food 26,699 Rental of Offlco Space Non food Supplies [, 500 Utilities Utilitms Office Supplies 200 Rent Office Building Mamtanance Equipment Use Fee Equipment Use Fee Rental of Equ~pmant 2,500 Audit Fees Transportabon .28 ~-~+5 I Legal Fees TransportationIi/ .28 Hob:I. le Phone 300 O~,er (~peclfy) Dme~ (~pec~fy) TOTAL 1 35,79! TOTAL 2 B Indicate projected income to the food servtca from all sources ot~er than SFSP reimbursement Identify exactly the costs ~s Income will cover (Do not include state or federal funds ) SECTION Ill-MANAGEMENT PLAN A. Est administrative level pemonnel who w~ll bo responsible for management and monitonog of the SFSP (Do not include s~ta supew~sors, cooks, janitors or other pemonnel involved ~n on s~te food aawtca ) - Dt]:ect:or ]. Co[tctuct:s ~:r;tin:i. ng sesaio~t, mo~.tt:o~: sit:es, S Are children charged separately for meals'~ ['~Yes i~No If yes, see Form 1508, Attachment B C Do you want to receive advance payments9 r-lYes r--~No Ifyes, 1 For Operalional Costs? i-~Yes ~"lNo 2 For Adm~n~alrative Costs? r~Yes ~""~No D ~f meal serwce ~s self-preparation, do you want to receive commodities? r~lYes [] No If yes, Form 1608 Applleat/oo and Agreement for Commod/t/es, must be completed SECTION IV-PROGRAM OPERATION A1 Begmn~ng and Endmg Dates of Meal Serv~ce From May 28, 1996 through August 9, 1996 2 Number of mtss 9 B Mst dates and top~c~ ~f SFSP training] 5/22/96 Site supervisor and monitor training on S.F.S.P. guidelines and Civil Rights training C Is the organization planning to contract w~th a food service management company for the preparation of unitized meals? [::]Yes r"~'l No If yes, and the contract will exceed $10,000, attach a cop~/of the invitation to bid Also give Also, attach a copy ol an Il<lay-cyme menu ~ndud~ng all specific menus to be used D Is the organization contracting with a year-round food eennce management company? [] Yea [] No If yes, submit a copy of your procurement procedures, bid, contract, and all amendments E Attach a copy of the letter which has been (or will be) sent by the organization to the Health Department notifying them of mtsnt to operate a Food Seance Program at the site(s) indicated on the attached S~te Information sheet (Form 1507) SECTION V-ASSURANCES A Free Meal Pohcy Statement 1 The contracting organization assures the Texas Department of Human Serwces (DHS) that all children at the mtas dasc~bed on the S~te(s) Informat4on Sheets for the Summer Food Service Program, wdl be offered the same meals w~th no physical sogregat~on of, or other d~scnm~nation agmnst, any child because of race, color, dmabillty, age, sex, national ong~n, rehg~on, or political behefs No separate charge wdl be made for any meal except in accordance with attachment B of thru apphcation 2 The contrac~og organization assures DHS that, if it is sponsonng camps or other enrollment programs · The contracting ,organization has or w~ll obtain family s~ze and income data about all children whose meals will be reported as free or · The children claimed as tree or reduced price meet the current famdy s~ze and ~ncome sta qdards set by the United States Department of Agriculture, DHS Form 4504, Standards for Determining Free and Reduced Price Ehgibility 3 If the contracting orgamzat~on m sponsonng a camp or other enrollment program Ihat charges separately for meals the contrec~ng organlzaUon has read Attachment B to th~s apphcat~on 'Additional Assurances lor Camps and Other Enrollment Programs tha~ Charge Separately for Meals" and assures DHS that all reclu~rements have been or w~ll be met B Pubhc Release 1 The contracting orgamzat~on wdl make efforts to ensure that the iocal news medm wdl make a public announcement ol the program and w~ll supply them with a news release If the contracting organization Is sponsonng a camp or other enrollment program, thru release must contall~, at a minimum, a list of all approved mtos, a hst of the current standards for determining free and recuded price ehgtb~hty, and the following statement it of enton "The {NC~a~t~the~n~r~c~r~'gan'zab°~l announces the sponsorship of the Summer Food Service Program Income eligibility will be based on family size and income using the Standards for Determining Free and Reduced-Price Eligibility, provided by the United States Department of Agriculture Meals will be provided at the sits(a) listed People who ara eligible to participate in the program must not be discriminated against because of race, oolor, national origin, sex, age, disability, religion, or political belief Anyone who believes that they have been dlacrimlnatsd against should write Immediately to Dlrsctor, Civil Rights Division, MC W-I06, Texas Department of Human Services, P O. Box 149030, Austin, Texas 78714.9030 or the Secretary of Agriculture, Washington, D C 20250 NOTE Discrimination complaints based on religion or political beliefs must be referred only to the Director, Civil Rights Division, Texas Department of Human Servloes" For all other programs the announcement must contmn, at a minimum a I~st of all approved sites and the following statement, "The (Na~f~ne~ntr~~a~izabOnl announces the sponsorship of the Summer Food Service Program Meals will be provided at the site(s) listed People who are eligible to participate In the program must not be discriminated against because of race, color, national origin, sex, age, disability, religmn, or political belief Anyone who believes that they have been discriminated against should write immediately to Director, Civil Rights Division, MC W-106, Texas Department of Human Services, P O Box 149030, Austin, Texas 78714-9030 or the Sscratsry of Agriculture, Washington, D C 20250 NOTE Discrimination complaints based on religion or political beliefs must be referred only to the Dlractor, Civil Rights Division, Texas Department of Human Services" 'this public release was or will be published ~n the followm~ news media outlet(s) NAME OF MEDIA OUTI. ET I DATE OF RELEASE NAME OF MED~A OUTLET DATE OF Denton Record Chronicle 5/1/96 TWU Student P~r 5/1./OF, Dallas MorninK N~s 5/I/96 k-DNT Radio 5/1/96 KNTU Radio 5/1/96 UNT Daily 5/'I/q6 3 Attach a copy of the contracang orgamzat~on's pubhc re,ease statement as submitted to the news media and any other matelJals used to publicize the program's avadabdlty and nondiscrimination requirements SECTION VI-CERTIFICATION (see Form 1506, Attachment C) I certify that the Information on this application is true and correct to the beet of my knowledge I certify that relmbumement will be claimed only for approved meals served to eligible chddren during the hours they are In attendance st approved eltss f know that dellberats misrepresentation or withholding of information may result In prosecution under applicable state and federal etstutse mgna~-O~f,c~ o~ Conu~,~; O~;an,zi~,on Date" Kyle Hogue Summer Food Coordinator , FOR DHS USE ONLY ~APPROVED C-]DENIED If denied, reaaon CITY of DENTON, TEXAS MUNICIPAL BUILDING · 215 E McKINNEY , DENTON, TEXAS 76201 (817) 566.8200 · DFW METRO 434 2529 February 21, 1996 Ms Laurie Callahan, Registered Samtanan Environmental Health Department 300 Woodrow Denton, Texas 76205 Dear Ms Callahan, The Denton Parks and Recreation Department is applying to the Texas Department of Human Semces for a grant to provide the Summer Food Semce Program to the cluldren of Denton This program ~ prowde lunch for cluldren ages I - 18 years of age The food preparation vail be contracted vath the Denton Independent School District We vail be serving sack lunches from ~gloos at the sites hsted below Tlus ~s a request that your department respect the locations of food semce Tune of ~ Dates Lunch Semce Civic Center Park 5/28/96 - 8/9/96 12 00pm-1 00pm 321 E McKmney Phoenix Park 5/28/96 - 8/9/96 12 00pm-1 00pm Wood Street Owsley Neighborhood 5/28/96 - 8/9/96 12 00pm- 1 00pm Stella Street Dema Park 5/28/96 - 8/9/96 12 00pm-I 00pm 1001 Parv~n "Dedtcated to Quahty Servtce" .~ TWU Clubhouse 5/28/96 - 8/9/96 12 00pm-1 00pm Mary Hufford Court Village East Apts 5/28/96 - 8/9/96 12 00pm-1 00pm 1700 Village East Houston Elem School 6/3/96 - 6/28/96 11 45am- 12 45pm 3100 Teasley Rayzor Elem School 6/3/96 - 6/28/96 11 30am-12 30pm 1400 Malone MLK Recreation Center 5/28/96 - 8/9/96 12 00pm-1 00pm 1300 Wilson If you have any questmns I may be reached at 566-8125 Brenda Burton Chtldren's Programs Super~asor Summer Food Service Program Sack Lunches Menus Eleven Day Cycle Tuesday - May 28 Peanut Butter/Jelly Sandwich 2 oz Peanut Butter, 1 T Jelly, 2 slices Bread Carrot Sticks 1/4 cup Banana 1/2 cup Lowfat lvhlk l/2 prat Wednesday - May 29 Bologna/Cheese Sandwich 1 1/2 oz Bologna, 1/2 oz Cheese 2 shoes Bread Carrot Corns 1/4 cup Maxed Fm~t 1/2 cup Potato Clups Lowfat 1Vhlk 1/2 prat Thursday - May 30 Tuna Salad Sandwich 2 oz Tuna 2 shces Bread Pinkie Spears 1/4 cup Orange Jtuce 6 oz Lowfat IVhlk 1/2 prat Fnday- May 31 Ham/Cheese Sandwich I 1/2 oz Ham, 1/2 oz Cheese 2 shces Bread Whole Pickle 1/4 cup Fruit Cup 1/2 cup Cookie Lowfat Milk 1/2 prat Monday - June 3 Deli Sandwich 2 oz Meat 2 slices Bread Pickle/Carrot 1/4 cup M~xed Fruit 1/2 cup Lowfat Malk 1/2 pint Tuesday - June 4 Peanut Butter/Jelly Sandwich 2 oz Peanut Butter, 1 T Jelly 2 shces Bread Carrot St~¢ks 1/4 cup Apple 1/2 cup Lowfat Iv~lk 1/2 prat Wednesday - June 5 Deb Sandwich 2 oz Meat 2 shces Bread Pickle/Carrot 1/4 cup Apple 1/2 cup Lowfat Milk 1/2 prat Thursday - June 6 Tuna SaladlSandw~¢h 2 oz Tuna 2 shces Bread P~¢kle Spears 1/4 cup Orange Jume 6 oz Lowfat Malk 1/2 prat Fnda¥- June 7 Ham/Cheese Sandwich I 1/2 oz Ham, 1/2 oz cheese 2 shces Bread Whole P~¢kle 1/4 cup Fruit Cup 1/2 cup Cookie Lowfat Malk 1/2 prat Monday - June 10 Bologna/Cheese Sandwmh 1 1/2 oz Bologna, 1/2 oz Cheese 2 shoes Bread Carrot Corns 1/4 cup IVuxed Frmt 1/2 cup Potato Ctups Lowfat Milk 1/2 prat Tuesday - June 11 Deh Sandwich 2 oz Meat 2 shces Bread P~ckle/Carrot 1/4 cup Banana 1/2 cup Lowfat IVhlk 1/2 prat Certification That Al__!l Required Pre-operational Site Visits Have Been Conducted At All Proposed Sites Name Of Person Name Of Site V~s~ted Date Of Visit Who V~s~ted S~te C~wc Center Park February 8, 1996 Brenda Burton Phoemx Park February 8, 1996 Brenda Burton Owsley Neighborhood February 8, 1996 Brenda Burton Dema Park February 8, 1996 Brenda Burton MLK Recreation Center February 8, 1996 Brenda Burton TWU Clubhouse February 8, 1996 Brenda Burton Village East Apts February 8, 1996 Brenda Burton Houston Elementary February 8, 1996 Brenda Burton School Rayzor Elementary February 8, 1996 Brenda Burton School Signature of Authorized Representative Date CITY of DENTON, TEXAS MUNICIPAL BUILDING · 215 E McKINNEY · DENTON, TEXAS 76201 (817) 566-8200, DFW METRO 434 2529 MEMORANDUM To Sohd Waste Department From Brenda Burton, Children's Programs Superx~sor Parks and Recreatmn Department Date February 9, 1996 Subject Summer Food Serwce Program The Summer Food Serwce Program, which prowdes sack lunches for children throughout the summer, is being sponsored by the Denton Parks and Recreatmn Department I would hke to make you aware that addmonal trash wdl be placed m dumpsters on Monday-Friday, May 28 through August 9 at the follovang locatmns C~wc Center Park Phoemx Park Owsley Neighborhood Dema Park MLK Recreatton Center TWU Clubhouse Program Village East Apartments Houston Elementary School Rayzor Elememary School If you have any questions please contact me at extension 8125 "Dedtcated m Quahty Servtce" :BUMMER FOOD SERVICE PROGRAM FOR CHILDREN CRIMINAL PROVISIONS AND PENALTIES 1 Whoever, In connection with any application, procurement, record keeping entry, claim for reimbursement, or other document or statement made in connection with the program, knowingly and willfully faisihes, conceals or covers up by any trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or whoever in connection with the program knowingly makes an opportunity for any person to defraud the United States or does or omits to do any act with intent to enable any person to defraud the United States, shaft be fined not more than $10,000 or imprisoned not more than five years 2 Whoever being a partner, officer, director, or managing agent connected In any capacity wtth any partner- ship, assoclstlon, cooperation, business, or organization, either public or private, embezzJes, mlcapplles, steals, or obtains by fraud, false statement or forgery, any benefits provided by the program, or any money, funds, assets, or property derived from benefits provided by this program, shall be fines not more than $10,000 or Imprisoned for not more than five years or both If the benefits, money, funds, assets, or property Involved is not over $200, then the penalty shall be a fine of not more than $1,000 or Imprisonment for not more than one year, or both 3 If two or more persons conspire or collude to accomplish any act made unlawful under this subsection, and one or more such person commit any act to effect the object of conspiracy or collusion, each shall be fined not more than $10,000 or Imprisoned for not more than five years, or both TERMINATION PROCEDURES The following list of deficiencies are grounds for termination Grounds for termination, however, are not limited to this list I Non..oompllanca with applicable bid procedures end contract requirements of Federal Child Nutrition ragu- latlons 2 The submission of false Information to the Texas Department of Human Services (DH$) 3 Program violations at a significant proportion of the sponsors' sites Such violations include but are not limited to the following' A Non-complianca with the meal service time restrictions B Fallura to maintain accurate records C Failures to adlu,~t meal orders to oonform to the variations in the number of participating chlldrem D The simultaneous service of more than one meal to any child E Service of a significant number of meals which do not Include required quantities of all meal components F The claiming of program payments for meals not served to participating children G Excessive Instances of off-site meal consumption H Continued uae of food service management companies that are in violation of health cod~s~ AGREEMENT TO FURNISH FOOD SERVICE CITY OF DENTON and DENTON INDEPENDENT SCHOOL DISTRICT FOOD SERVICES THIS AGREEMENT is made and entered into by and between the Denton Independent School l~stnct and the City of Denton Denton Independent School District agrees to supply umtlzed meals lnclustve of walk and jmce to the Ctty of Denton Parks and Recreatton Department. at the MLK Recreation Center, Phoemx Park, Dema Park, Civic Center Park, Owsley Neighborhood, TWU Playhouse Program, Village East Apartments, Pavera Elementary Summer School, and Wilson Elementary Summer School, wath and for the rates herein listed Breakfasts $ 0.00 each Lunches $ 1.55 each Snacks $ 0.00 each Supper $ 0.00 each It is further agreed that the Demon Independent School District. pursuant to the provisions of the Summer Food Serrate Program Regulations, a copy ofwluch is attached as Exlubit "A" and ts part of tlus agreement, wdl assure that smd meals meet the rmmmum reqmrements as to nutritive value and content as outlined m the U S D A.'s Sponsor Meal Preparation Handbook, and wall mamtmn full and accurate recordings of such, mcludm8 the follovnng I Menu Records, including amount of food prepared 2 Meals, including dmly number of meals delivered by type These records must be reported to the mst~tution promptly at the end of each month Denton Ind .ependent School District agrees also to retain records required under the preceding clause for a penod of three years and 90 days aRer the end of the contract period If audits, clmms or litigation have not been resolved, all records must be retained beyond the required ttme period until all tssues are resolved tn accordance wtth the Summer Food Semce Program Agreement between The CtW of Denton and The Texas Department of Human Services The Denton Independent School [hstnct agrees to comply with the reqmrements of the Imrmgratlon Reform Control Act of 1986 regardmg employment venficatton and retention of venficatton forms for any mdtvaduals lured after November 6, 1986 who will perform labor or servaces under thts contract The Denton Ind _ependent School D~smct agrees to allow for purposes of audit, exanunatlon, excerpt, and transcription, the USDA, the Comptroller of the Umted States, D S and any of their authorized representataves to have access to any of the contractor's books, documents, papers, and records that are pertinent to the contract The Denton Inde.~dent School 12hstnct agrees to comply w~th the reqmred mandatory standards and pohcies concermng energy effictency contained in the Texas Energy Conservation Plan tssued in comphance vnth the Energy Policy and Conservatton Act (P L 94-163) The Denton Independent School District agrees that except for small purchase contracts, provaslons that allow for adrmmstrattve, contractual, or legal remedtes if contractors v~olate or breach contract terms, and any appropriate sancttons and penalues The Denton Ind .ependem School [hstnct agrees to be tn comphance vnth Sectton 103 of the contract Work Hours and Safety Standards Act (40 USC 327-330) as supplemented by the department of Labor regulattons (29 CFR, Part 5) Under tlus Act, contractors must compute the wages of mechamcs and laborers on the bas~s ora standard work day of etght hours and a standard work week of 40 hours Work that exceeds the standards must be compensated at least 1 ½ times the basra pay rate for overttme hours worked These reqmrements do not apply to the purchase of supphes or materials ordinarily avmlable on the open market or contracts for transportation The D~ntcm Independent School District agrees to comply w~th Executive Order 11246 entitled "Equal Employment Opportumty" as amended by Executive Order 11375 and as supplemented m Department of Labor regulations (41 CFR, Part 60) The Denton Independent School District agrees to comply w~th all other applicable laws, including w~thout hrmtatlon, any additional applicable Federal Laws or regulations contained in the Summer Food Servme Pro_~ram A_m'eement between the ~ and the Texas Department of Human Sermces. If the Denton lnde.~ndent School D~stnct fads to prowde sermces in accordance w~th the prowslons of this contract, the CIty of Denton may, upon written nouce of default to the contractor, immedmtely ternunate the whole or any part of flus contract The agreement shall be effecuve as of Ma,y.2_a,,_Lg~ It may be ternunated by not,ce m writing given by any party hereto to the other parties at least 30 days prior to the date of termination IN WITNESS WHEREOF, the part~es hereto have executed flus agreement as of the dates indicated below Agreed to tlus date ~'/~/~ q. Agreed to ttus date.'5'///2 //~ Sponsor Official ~_~__~.~.___~ School Sponso Title _._. City ~nna~.r Title DISD School Board President The location of the food preparation me will be Houston Elementary School, 3100 Teasley Denton, Texas, 76205 of Human ~enaoes SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR OHS USE ONLY SITE INFORMATION ~ Owsley Park ~ddress of S~, (S~ C~, Sm~, m~ I (817) 566-8125 Stella'Street Denton, TX 76201 From 5/28/96 thmul[Ih 8/9/96 eratlngDsys 4 20 Y 22 ~Aug 7 A'ITACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED r'"l Residential Camp r-'l Site Serving Primarily Migrant Ch dran Other Site 1 Indicate Type of Site I I A.(ssrving one to four meats) [ I C (sew ng one to four meals) [] E (sewing one to four meals) Nonresidential Camp I--1 Site Serving Primarily Homeless Children [] B (serving one to four meals) I I O (serving one to four meats) 2 Uet ALL COunties served by this site Denton 3 A IS your site open []Yea [] No B la your site enrolled? []Yea [] No C Site Eligibility Enter the percentage o~ c~ildren eligible for free and/or reduced price meals for the site (SFSP Handbook, Chapter II) 19 % D If open sites, submit documentation supporting this percentage tigum (such as census date, school data) For open sites using school data, list the schools used to document site eligibility, attach formula used by school dmt. to establish percentage of free & reduced pdce children Census data from FACAA E For enrolled sites, Form 1531 will be used to document ehgibility If the enrolled site used school data, list the school used to document the site F What is the percenlage of free or reduced-price meals for the site? 100 4 Did the site participate In previous years' SFSP? (SFSP Handbook, Chapter if) I"~yea []No If Yes, give name of contracting organizahan City of Denton 5 Monltonng Plan (SFSP Handbook, Chapter lfl) Enter date of monitoring renew to be conducted within 5/31/96 6/12/96 7/17/96 6 MealDowlcePeriod, lnformation SFSPHandbook, Chapterll) TO BE eERVED' BEGINNING ENDING A M Supplement Lunch 40 12 00 D.m, 1 00 p.m. P M 7 Do you plan to feed children under one (1) year old? E::]Yes [] No 8 Method of Food Prel~aratlon by Contracting Organization (SFSP Handbook, Chapter II) Seif ;'~,.,,-~, Vended Using School ,-., Using Food Service Management Using Private Non Proflf [] On Site [] Central Kitchen [] Food Authority L_J Company/(includes All Year ContractsI [] Or~ar~;~;;~ii that Is Self Prep I I ~ 9 indicate the system to be used for the serving of meals and the supewision of children during meal sewice period (SFSP Handbook, Chapter II) [..] CalsteflHtyle ~ Children are Seated ~ Children Line Up Mcel service I I and are Given Meals ~ and Pick Up Meals [] Other o will be involved to any ext~P Handbook. Chapter II) ........ ,o 1 Supervise and assist distribution of meals monitor Site Supervisor ~and maintain meal tam erature- ~ ___-------- ----------- other duties as as i ned 1 11 Indicate what provisions will be made for meal sedco dunng pedods of inclement weather (SFSP Handbook, Chapter II) [~lndcor Meal ,.--,Meal Service Service I IWlll Be Cancelled [] Other 12 if the stie fseds ~marily bemeless children, whal methods are used to ensure that m°neY, I°ad stamps' °r In kind sewlcee are n°t tequirad I°r meals? N/A ~ [~IYea [].o 13 Am meals dalivemd to the site? IF YES, COMPLETE ITEMS 14, 15, & 16 IF NO~ FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM ' Indite the means of communication with the vendor whiCh will be used to adjust meal deliveries (SFSP Handbook, Chap 14 ,..-,Sits Perseanal Wilt Communlcete ,..,Site personnel Will Contact .Administrative L_JDhectly With Vendor I~ JStaff, Who Will Contact Venaor ~---~Ye, line 15 Will dalivmy be within one hour of the food service perK)d? ($F-qP Handbook, Ch~ter II) ff no, describe anmngemants within stGndBrds prescobed by lo,al health 8uthortties for dalivmy and helding of meals until time of ltl If there is an exce~s of meals delivered, meals will be (SFSP Handbook, Chapter Itl) i~.~Ste~d in Relrigemtor r....~Threwn Awsy Itetumed to Vendor []Other' - - ~cl Served the Next Dny ll~t the Site lot Diedo~l m knowled · certily that this site has been visited ~nd that it nfo etlon on this Iorm is t~e and correct ? the be. st_o_f, ~,., ..... ~. d know that de berate mlsrepmsantotion or I CERTIFY that the I . ri?.,., ,_... .... i .o,~,~, nlanned for ~ne numuur u, u.,..- ..... ,.ate has the capablitiy and laCtltaes lu, u,=..,- .... ' ':-":- %-.~*. -..,~ le state end federal st? withholding of thfon'nation may result In prosecuuu. ...... ~.rlicab ~/ ENema of c,~n~,~ng O~..,~,~ , ACLU OF VII{GINIA FAX of Huma~ Se~ce$ SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY SITE INFORMATION Den.la Park ~ .~d,~. of S~e (S~ee~ c~/Sm~ ~ ( 817 ) 566 - 8125 qddq ~w~'~n Denton, Texas 76201 From 5/28/96 mmu~h 8/9/96 em~ngDays 20 y 22 ~ A~ACH A MAP W~H ~E Sl~ SERVICE AREA IDENTifIED ~ Residential Camp ~ S~ Seining Primarily Migrant Children Other Site 1 Indl~te Ty~ of Site ~ ~ (~wlng one to tour meala) ~ C (sewing one to four meals) ~ E (seining one to tour meals) D Nonmslden~l Camp ~ Slte ~wlng PHmarl~ Homele~ Children S (aewing one to tour m~ls) ~ D (se~ing one to four meals) 2 Ust ALL munUes sewed by ~ls site Denton 3 A Is your site open ~Yes ~ No B Is your rote enrolled? ~Yes ~ No C Site Eliglbill~ Enter ~e ~nmge of ~ildren eligible lot frae ancot mdumd pnm meals for the ate (SFSP Hand.k, Chapter II) 64 % D If o~n sees, submit d~mentat~on suppling this permntage figure (such as ~nsus date, school data) For o~n sites using s~l dam, list ~e ~ls ~ed ~ do.merit s~e elig~bili~, a~ fo~ula used by ~h~l dist to estabhsh per. hinge of free & r~u~ p~m ~ildren Census data from TAC~ E For enrolled mtgs, Fo~ 1~1 will be us~ to d~ment ellgiblli~ If ~e enrolled s~e us~ s~l dam, list ~e s~l used to d~ment ~e site F ~at Is ~e ~nmge of frae or mdu~d-p~ meals for ~e sNe? 100 "A 4 Did ~ sim ~dpam In previous yearn' SFSP? (SFSP H~ndbook, Chapter II) ~ Yes ~ No ff Yes, give name of, ~n~a~ng o~anizaaon C [ ty O f Den ton 5 Monito~ng PI~ (SFSP Handb~k, Chapter [11) Enter date of momtoring review to be ~ndu~ed w~in 6/~2/~ 6 Meal Sew~ Ped~ Info~aaon (SFSP Handboo~ Chapter II) A M Supplement ~n~ RN 13_ p:m: 1,nN ~-m, P M Supplement 7 ~ you plan to feed ~ildren under one (1) year old? ~ Yes ~ No 8 Meth~ of F~d Prep~aUo~ by Oonva~i~g O~anlzation (SFSP Handbook, Chapter II) ~ ~a~n Ve~ Using ~h~l ~ Using F~ ~lce Management ~ Using~Pdvate Non Proffi I D On Site D Central Kltche. ~ F.d Author~ ~ Compan~ <includes All Year Contracts) D O,~i,i,.iion ~at Is Self Prep I 9 Indicate the system to be used for the serving o! meals and the supervm~on of children dunng meal service period (SFSP Handbook Chapter II) [._~Cafeterta-style ~ Children sro Seated r~m Children Line Up Meal Service [_.J and ere Given Meals ~ end Pick Up Meals [] Other 10 Ust site personnel who will be involved to any extent in the meal service (SFSP Handbook, Chapter ~lte Supervisor ~ Sue ise ssis other duties as assi n~q~_ 11 Indicate what provmions will be made for meal service during benods of inclemant weather (SFSP Handbook, Chapter II) r~lndoor Meal ~Meal Service ~rvice I IWill Be Cancelled F-~other 12 ff tho site feeds ~mmtly homeless children, what methods ars used to ensurs that re°neY, f°°d stamps' or Iff kind services are not requited for moab? 13 Am me-la delivered to the site? IF YES, COMPLET~ ITEMS 14, 15, & 16 IF HO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM 14 Indicate the mens d communication w~h the vendor whtch will be used to adjust meal deliveries ($FSP Handbook, Chap II) ,.-.~ Site Per~oncet Will Cammunlcats ..-qSite Peraonnol Will Contact Administrative ~.J DlmCity With Vendor I~ IStaff, Who Mil Contact Vendor ['~Yes [:~.o 15 Will delP/ely be within one hour of the food service boned? (SFSP Handb°°k' Chapter ti) Il no, describe arrangements within standards prescribed by local health authorities for dehvory and holding of male until time of se~ce 16 iftharelsanexcassofmealsdeliversd, meals will be (SFSPHandhook, Chaptertil) [~Stored In Refrigerator r._tThrown Away ,.--, Returned to Vendor and Served the Next Day I lat the Site I I for Dlepoeal []Other of know edge ceflify th-t this site has been visited and that It the thformaIton on this form ts true and co?e. ct ~ _the. be,,.s_t...,m~y .t. n cinated I know that deliberate misrepresentation or I CERTIFY that ...... .,__ ~_. v.... -,-,et service nlanneo for me .ut.u-. ,.,. ...... an a ti ,- has the capability asa M;.uu=~ ,u~ .,= withholding of information may result in prosecution under applicable state and lederal '/ //) ~,~.~0 "~ ~ City' o~ Denton o~.fl~o.~~ Coordinator ACLU OF VIRGINIA FAX ~i 1~, 1~ of Human Se~ces SUMMER FOOD SERVICE PROGRAM FOR CHILDREN I FOR DHS USS TNLY SITE INFORMATION 'N,~of Fo~ Se~,~ s;m TX I--IR Rayzor Elementary School [,e~ep~o~eNo (~ ~C) ~re.o~Slm(s~Ci~,Sm~,m~ ~ (817) 566-8125 1400 Malone Denton, TX 76201 Pe~ of ~,~ of F~ ~w~ (~day~ ~J~ay~ ) ~ May Ju~ From 6/3/96 ..u~h 6/28/96 ~ Num.rofO. ~ 20 ~Ju~ ~Aug orating Days A~ACH A MAP W~H ~E SI~ SERVICE AREA IDENTIFIED ~ Residential Camp Site Se~ing Primarily Migrant Ch dren ~ Other Site 1 Indi~te Type of Site ~ ~ (~wlng one te four meal~) ~ C (seining one te four meals) ~ E (se~in~ one to tour meals) ~ Nonresidential Camp S~e Se~ing Pdmad~ Homele~ Ch Idren B (se~ing one te four m~ls) ~ D (seeing one to four meals) 2 Mst ALL ~unhes seined by ~is site ~e~t o~ 3 A Isyoorsimo~n ~Yes B Is your s~m enrolled? ~Ye~ ~ No C Sim Eligibil[~ Enter ~e ~n~ge of ~lldren ehg~ble lot frae ~or ~u~d pn~ me~s for the rote (SFSP Hand.k, C~pmr II) 0 D If o~n sites, submit d~umen~hon supposing ~is per~n~ge tigure (such ~ ~nsus date, school data) For o~n sites umng I~t ~e ~ls ~ed ~ d~ment site ehg~bili~, a,a~ fo~ula used by ~1 d~st to estabhsh per~n~ge of free & r~u~ pd~ ~ildren E For enrolled sites, Form 1531 will be used to document eligibility If the enrolled site used school data, hat the school used to document the site F What is the percentage of free or reduced-price meals for the site? I00 % 4 D~d the site participate in previous yearn' SFSP? (SFSP Handbook, Chapter II) ~lYea J'~'lNo I! Yes, gnre name of contracting orgamzation 5 Momtonng Plan (SFSP Handbook, Chapter III) Enter date of momtodng rewew to be conducted within Jur~e 4 June 1 6 Meal Service Period Information .~FSP Handbook, Chapter II) Breakfast A M Supplement Lunch [50 ~1.30 P M Supplement Supper 7 Do you plan to feed children under one (1) year old? [] Yea [] No 8 Method of Food Preparation by Contracting Organization (SFSP Har~dben_k Chapter II) Serf c~.~..~,, Vended Using School ~ Using Food Smvice Management Using Private Non Profit j [::]0n Site J-'l Central Kitchen [;'~ Food Authority U Compan, ('ncludes All Year Contracts)r~ Gr:/-,~;~.-;;.~n that Is S,, Prep 9 Indicate the system to be used for the serwng of meals and the supervision of children dunng meal service period (SFSP Handbook, Chapter II) [,~Cafetarla-style ~ Children are Seated ~ Children Line Up Meal Sandea L.-J and are Given Meals ~ and Pick Up Meals [] Other who will be involved to any exle~ Handbook, Chapter II)' ___ 10 Est alte personnel who wlfl ge ~n~ -.------------ ~ I Superw~se and assist distribution of meals, monitor___~___ ~upervisor and maintain meal temperature, site clean-up, and other duties as assigned ~ i Assist site supervisor ------------ Site Helper/Server ----------- 11 indicate what provisions will be made for meal service during periods of inclement weather (SFSP HandbOOk, Chapter II) [~h~dcor Meal ,...~ Meal Service Servile ~.J Will Be Cancelled [~ Other 12. If the site leeds pdmarfly homeless children, what methods are used to ensure that money, tcod stamps, or in kind sewtcas are not required tar meals? --- ./A __ ELY,, []"o 13 Are meals delivered to the site? IF YES, COMPL~' t'E FTEMS 14, 15, & 16 IF NO, FORM IS COMPL~' f E EXCEPT FOR CERTIFICATION AT Bo'FroM 14 thdilate the means of communication with the vendor which will be used to adjust roeal dalivefles (SFSP Handbook, Chap II) ,--..~ Site pereonnal Will Communicate ,.-, 8ire Pemmlnal Will Gontect Administrative lIDirectly With Vendor ~ Staff, Who Will Contact Vendor [~y. [-~No Will dal~vmy ho within one hour of the food servtca peru)d? (SFSP Handbook, Chapter II) 15 if no, dascdbe arrangements within standards prescribed by local health authonties for deflvan/and holding°f rcaals undl time of service 16 if there is an excess of meals delwered, meals will be (SFSP Handbook, Chapter Ill) [~,]$tored In Refrigerator r._tThrown Away ,.-.~Retumed to Vendor - a~d Sewed the Next Day I lat the Site iIfor Dispessl []Other f know edge i certify that this she has been visited and '~at It .........'A~'*[On On this form iS true and correct to the beat o .m~y ..... =-~-"'~'d I know that deliberate roiarepresentetion or I CE..RTII'¥ ~,,t~t~.u.~,~,.,~,~. fn e meal service &armed for the nurober o! Chi,ore. m,.~..,~ has 111o copao...y a.,, ,,- ........ r th P under applicable state and tederal _~!-_~[~ms ,-~ on , l Name of conuacti~g O~g~lzam3~ ~ o of Human Senr~oes SUMMER FOOD SERVICE PROGRAM FOR CHILDREN I FOR DHS USE ONLY SITE INFORMATION TWU Clubhouse Program ~ (817) 566-8125 Mary Huffor~ Court Denton, TX 76201 emUng Days A~ACH A MAP W~H ~E SI~ SERVICE AREA IDENTIFIED ~ Residential ~mp Site Sewing P~ma~ly Migrant Children 1 Indi~te TV~ of Site ~ ~(~wlng one to four meals) ~ C (aewlng one to four meala) ~ E (sewing one to four meals) ~ ~nmsldenlbl Camp Sfle ~wing Pdma~ Homele~ Ch dren B (~g one to four reeds) ~ D (sewing one to four meals) 2 ~st A~ ~untlas se~U by ~ls site ...... 3 A Is your site open ~Yan ~No B Isyourmteenmlled? ~Yes ~No C SI~ Eligiblli~ E~r ~e ~ of ~l~ren eligible for free an~or r~d pn~ mea~ f~ the rote (SFSP Hand.k, C~pter II) 19 D If o~n seas, submit d~umen~tion sup~Alng this ~r~ntage figure (such ~ mnsus date, school data) For o~n sltas using ~1 da~, I~t ~e s~ls used ~ d~mant s~e ellglbili~, a~ ~ula used by sch~l dlsb to es~biish per~n~ge of free & r~u~ p~ ~lldmn Ce~us da~a ~om ~AC~ E For enrolled sites, Form 1531 will be used to document eligibility If the enrolled site used school data, list the school used to document the site F What Is the percentage of free or reduced.price meals for the site? 100 4 Did the site participate In previous yearn' SFSP? (SFSP H~ndbook, Chapter II) I"~"IYes [] No IfYes, give name of oontracting organization City of Denton 5 Monitoring Plan (SFSP Handbook, Chapter 111) Enter date of monitonng rewew to be conducted within ~ A. Fir~! Week ~ ] 5/31/96 6/12/96 7/[7/96 Meal Sen'ice Pedod Information (SFSP Handbook, Chapter I1) ~PES OF MEAL~ EUGlaLE CHILDREN MEAL SERVICE ~ME TO BE SERVED' BEGINNING ENDING Breakfast A M Supplement Lunch 55 12 00 p.m 1 00 p.m. P M Supplement Supper 7 Do you plan to feed children under one (1) year old? []Yes [] No 8 Method of Food Preparation by Contracting Organization (SFSP Handbook Chapter II) F°°~ Auth°dt7 r'l C°mpany (l~¢!"de~ AIl Year Contracts 9 Indicate the system to be used for the serving o! meals and the supervimon of children during meal service period (SFSP Handbook. Chapter II) r_] Cafeteria~tyle ~ Children are Seated ~ Children Line Up Meal $ervise ii and sm Given Meals ~ and Pick Up Meals [] Other Ust site personnel who will be involved to any extent m the meal se;vice (SFSP Handbook, Chapter Ii) tO Site Supervisor 1 Supervise and distribute meals~ monitor and maintain ~ ~ meal temperature, site clean-up, and other ---------- duties as assigned ___.__ 11 thd~ate what provlmons will be made for meal service during panods of inclement weather (SFSP Handbook, Chapter r~Mdoor Meal ,-.,Meal Service ~r~ise ~ Will Be Conceited [] Other _ 12 ff the site feeds ~m~ly h°meless childran' what metheds am used te ansure thst m(mey' f°od stemps' °r th kind earvtcas me n°t requited f°~ meals? N/A ~ F~]Yee r~No 13 Are meals delivered to the site? IF YES, COMPLETE ITEMS 14, 15, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM 14 indicate the means of nommunication with the vendor which will be used to adjust meal deliveries (SFSP Handbook, Chap ii) ~Site personnel Will Communicate ,,_-_.,Site pemonnel Will Contact Administrative liDirectly With Vendor I~lStaff, Who Will Contact Vendor Will del~vanj be within one hour of the food service period? (SFSP Handbook, Chapter II) 15 il no, dascdbe arTangemants within standards prsscnped by local health authormes lot dehver/and holding°f melds until time °f service 16 If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter Iff) E~Stored In Refdgerstor r-.1Threwn Away r.-~Retumed to Vendor - and Sewed the Next Day list the Site I Ifor Dlspcest E~Otber I CERTIFY that the Infonllation on this form is true and correct to the beet of my knowledge i certily that this site has been visited and that it has the ~apablllty and fantiitJee for the meal service planned for the number of children anticipated i know that deliberete misrepreaant"Uon or withholding of information may result in proseCubon under applicable state and federel statutes °~e~S mm e~ ~ood Coordinator ACLU OF VIRGINIA FAX or Human Se~=es SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY SITE INFORMATION Village East Apartments ~,;~"~fSdto(St;oe~c~tv,Smte ziP) I (817) 566-8125 1700 Village East Denton, TX 76201 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED ~ Residential Camp r'"l Site Serving Primarily Migrant Ch dren ~ Other Site 1 Indicate Type of Site I I A.(sewing one to four meals) I I C (earvlng one to four meals) I..[J E (serving one to four meals) ] Nonresidential Camp r-1 Site Serving Primarily Homeleu Children B (ea~vlng one to four meals) I I 0 (serving one to four meals) 2 Ust ALL counties served by thte s~te ~ne~t or~ 3 A Is your site open []Yes [] No B Is your site enrolled? []Yes [] No C Site Eligibility Enter tho percentage of c~lldrefl eligible for free and/or reduced pnce meals for the site (SFSP Handbook, Chapter Il) 10 0 % D If open sees, submit documentation supporting this percentage figure (such as census date, school data) For open sites using school data, list the schools used to document site eligibility, attach formula used by school diet to establish percentage of free & reduced price children Census data from TACAA E For enrolled s~tes, Form 1531 will be used lo document eligibility If the enrolled site used school data, list the school used to dooument the site. F What Is the percentage of free or reduced-price meals for the slte? 1 O0 % 4 Did ~e site parbctpate in previous years' SFSP? (SFSP Handbook, Chapter Il) F~lYea []No If Yes, give name of contracting organizahon . Ct r y ~ f ~n r n n 5 Monitoring Plan (SFSP Handbook, Chapter III) Enter date of momtoring rewew to be conducted within 5/31/96 6/12/96 7/I7/96 6 Meal Service Period Information SFSP Handbook, Chapter I1) Breakfast A M Supplement Lunch 50 12.00 p,m, P M Supple,~,t,,,~. S,,pper 7 Do you plan to feed children under one (1) year old? [] Yea [] No 8 Method of Food Preparation by Contracting Organization (SFSP Handbook Chapter II) Set~ r~,=,.~, voraod Using School Using Foo~ Sen~ico Management Using Private Non Profit I I~0nSlte [~CentralKllchen ~ Food Authority ~-ICompan~'(l""h,d?~AIIYearContracta) [~Of~a,,iz. aiion that ls Self Prep 9 indicate the system to be used for the serving of meals and the supewmion of children during meat service period (SFSP Handbook, Chapter II) [:::]Calsterla-~tyls ~ Children are Seated ~1 Children Line Up Meal Service I I and ere Given Meals ~ and Pick Up Meals [] Other 10 Ust site personnel who will be ~nvolved to any extent m the meal service (SFSP Handbook, Chapter II) 1 Supervise and assist distributi Site Supervisor other duties &s~ Site Helper/Server 1 Assist site su er iso ~ ----------- 11 Indleate what provisions will be made for meal service dunng periods of Inclement weather (SFSP Handbook, Chapter r~lodOor Meal ,....~ Meal Service Service I IWlll Se Cancelled [~Othat _ 12. ff the site feeds ixtmatily homeless children, what methods ate used to ensure that money, food stamps, or In kind earvises ate not required fat meals? []Y. [3.° 13 Am meals delivered to the site? IF YES, COMPLETE ITEMS 14, 15, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BoI'rOM 14 IndiCate the means of communication with the vendor which will be used to adjust meal deliveries (SFSP Handbook, Chap II) ,.~ Site persm~nal Will Communicate ~SIte Personnel Will Contact Administrative L-] Directly With Vendor L.,~J stoff, Who Will Contact Vendor Will dalwe~y be within one hour of the food service period? (SFSP Haodbook, Chapter II) 15 if no, dessrlbe an. angements wttthn standards preschbed by iocel health anthoritles for dallve~/and holding °f meals until time °f sewl°e 16 If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter lit) [,~Stored In Refdgerster r_~Thrown Away ...~Retumed to Vendor - and Served the Next Day I tot the Site L-,J for Oledossl [] Other' f knowledge I certify that this site has been vJaltod and that it e Information on this form is aue and corr. e. ct ~ _th~._be~s~t.o~,m~Y,a' dealed know that deliberate misropresantaUon or CERTIFY that th ...... , - ~ .... ~ ~,rvice nlannea for me .u,,,u~. ~- ...,..eh anti . withholding of Intormat~on may result n prosecubon under apphceble state and · ----  --~eu~er Food Coordinator ed ['~ Denied, resson ACLU OF VIRGINIA FAX 2] ~ f,,~,~; ~,,~) FROM: Stil C~ Fo~m 1507/Page 2 9 Indiceto the system to be used for the serving o! meals and the suPervlsiofl of children dunng meal service period (SFSP Handbook, Chapter II) [...~Calaleda-alyle ,..., Chi dren are Seated ,...., Ch dren Line Up [] Other Meal Service L-J end am Given 14ca s L~ end Pick Up 14eels xtont in the m~P Handbook, Chapter J?_ ......... · -~*e ,~ersonnal who will be involved m any ex ~l smv,~ V~o° s£nVlCE nnO~aAa CUtlaS 10 JS~ o,, ~. SmON 1 ~nd dl¢~,trlbute meals ~ ---------- maintain meal te erature - ~ other duties as ass~ ned -------- 11 Indicate whm provisions will be made tot meal service dunng periods Of Inclement weather (SFSP Handbook, Chapter 8) [~lndcer 14eal ~Meal servl~e [] Other Service [_.JWtil Be Cancelled 12 ff the site teeds ~mmtly homeless children, whal methods are used to ensure that m°ney' I°od stamps' or in kind earvlces are n°t required ior meals? I'ZN.a F'I.o 13 Are meals delivered to the site? IF YES, COMPLP-i ~- ITEMS 14, 15, & 16 IF 140, FORM I$ COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM Indlceto the means of communlcetlon with the vendor which will be used to adjust meal deliveries (SFSP Handbook, Chap II) 14 ,...Site personnel Will Communicate ,...~ Site pe~O~nsl Will Contact .Administrative ~._.J Directly With Vendor I~ IStoff, Who Wilt contoet VenaOr [~"~ Yes []No 15 Will del~vem/be within cee hour of the food service penod? (SFSP Handb°°k' Chapter II) Il no, descflbe m~sngemente within standards proscribed by local health authorlt~es for deliver/and holding of mens until time of 16 il there ls an exceea of meals dallvemd, meals will be (SFSPHandbook, Chaptertlt) r-~Stored in Refilgemtor ,,_..~'fhrown Away ,.-,Returned to Vendor [] Other _ - - ~and Sewed the Next Day L-Jet the Site L..J for Disposal 1 CERTIFY that the Inlon~ation on this ton~ is true and co~eCt to the best of my know edge I certlly that this site has been visited and that it I d tacttities tot the meal serv ce planned for the number of children anticipated I know that deliberate misrepresentaiton or h~s the nspabl Ity ~ ........ ,*,on under appl~cebte state and tederal statutes wknholding o! intormation may reeuK in , ~ , I /~ -, ~,/ ~ C~ty o~ Denton -- ,/ t/ LL ...... -- ~1~\ _.~-~.l-~ - L -~-"~...7--:------- -- ~ d ~'-"=' Tee ~__.~ ~ nator Su~nmer Food CoordlnatO Texas SUMMER FOOD SERVICE; PROGRAM FOR CHILDREN ~ FOR OHS USE ONLY SITE INFORMATION ~ J {~7) 566-8125 ~}~_.~s ~ . Denton, Texas 7~20 A~ACH A MAP W~ ~E Sl~ SERVICE AREA IDENTIFIED ~ Resldenllal Camp Site Sewing PdmaHly B grant Children ~ Ot~r Site I Indi~te Ty~ of Site ~ ~ (~wing one to four meals) ~ C (sewing one to four meals) ~ E (se~lng one to four m~l~) Nonresidential Camp ~ S~e Serving PHmaH% HomeleM Chlld~n ~ 8 (se~lng one to four m~ls) ~ D (sewing one to four meals) 2 MstA~ mun~es sewed by ~ls site 3 A Is your site open B Is ~ur site enrolled? ~Yee ~No C S~ EIIglblllN En~ ~e ~n~e of ~lldre. eligible for free an~or r~u~ pdm meals I~ ~e s~ (SFSP Hand.k, Chapter II) 0 % D If o~n s~es, submit d~umanta~on suppo~ng this parentage figure (such as mnsus date, ~hool dala) For o~n sites using s~l da~ I~t ~ ~ ~ed ~ do~ment s~e ehg~biltN, a~ fo~ula used by ~h~l dist to establish pe~nmge of frae & ~u~ prim ~lldren E For enrolled sites, Form 1531 will be used to document ellgibilrty If the enrolled site used school data, list the school used to document the s~te., F What Is the percentage of free or reduced-price meals for the site? 4 Did the site partldpeta In previous years' SFSP? (SFSP Handbook, Chapter II) r-]yea J'~No If Yes, give name of contracting organization Meal Service Period Information...___.. (SFSP Handbook, C........_.._.__._.~hapter ti) HUMBER OF TYPES OF MEALS ELIGIBLE CHILDREN -. MEAL SERVICE TIME TO BE SERVED* BEGINNING ~ ENDING Breakfast A M Supplement ---'------"------- Lunch ~ 30 11: 45am ~ 12: 45pm P M Supplement Supper 7 Do you plan to feed children under one (1) year old? []Yea [] No 8 Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter ti) SUMMER POOD SERVICE PROGRAM FOR CHILDREN FOR OHS u$£ ONLY - SITE INFORMATION  L (817) 566-8125 .... · ~ Lo =0 ming n ~ ~ 96 eratingDaya ¥ 4 22 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED ~ Realdenital Camp Site Serving Primarily Migrant Ch dren Other Site 1 Indlcete Type of Site I IA.(~ervlngo~etefourmeals) [--~C(servingonetotaurmeals) [--~E(aervlngonetefourmeala) ] NonrasldootiaICamp r--i Site Serving Primarily Homaleu Children B (~orving one to four meals) i i D (aervthg one to four meals) 2 Mst ALL oounties served by this sita Dantnn 3 A ta your site open ~Yes E]No B Is your site enrolled? []Yes [] No C Site Eligibility Enter the percentage of children eligible for free end/or reduced price meals for the site (SFSP Handbook, Chapter ti) -, 31 % D If open sites, submit documentation supporting this percentage figure (such as census date, school data) For open sites using sctmol data, list the schools used to document site eligibility, attach formula used by school dist. to establish percentage of free & reduced price children Census data from TACAA E For enrolled sites, Form 1531 will be used to document eligibility If the enrolled site used school data, list the school used to doocment the site F What Is the peroontage of frae or reduced.price meals for the alta? 100 % 4 Did the site partlclp~ta In previous years' 8FSP? (SFSP H~ndbook, Chapter it) F'~Yea [] No If Yes, give name of contracting organization City of Denton 5 Monitoring Plan (SFSP Handbook, Chapter III) Enter date of momtoring rewew to be conducted w~thm 6 Meal Service PeriodIlnformatim (SFSP Handbook, Chapter II) Breakfast A M Lunch , 90 12.00 P,m, 1 00 p,m, P M S.pp!ement i Supper 7 Do you plan to feed ~hildren under one (1) year old? E] Yes [] No 8 Method of Food Preparatico by Contracting Organization (SFSP Handbook Chapter II) [Serf P,-:---!~-n Vended~ Using School Using Food Service Management Using Private Non Profit I [] On Site [] Central Kitchen L-~ Food Authority [] Company II-.],,~ All Year C~.t~ac;~) [] C~¥.,~i;~.-~;~ that Is Self Prep 9 indicate the ayatem to be used lor the serving of mea~s and the supervision of children during meal service period (SFSP Handbook, Chapter II) ~._] Caleter~Htyle ~ Children are Seated ,.., Children Line Up Meal Sewlca La and are Given Meals L.~ and Pick Up Meals [] Other will be involved to any ext~P Handbook, Chapter II) -- ~ OF poamoN ~ ~ n~ meal s, monitor Site Supervisor Supervise and assist distribution of mea , and maintain meal temperature, site clean-up~ and other duties as assigned 1 AssiSt site supervisor Site Helper/Server 11 Indi~ta whet provisions will be made for meal serwca dunng periods of Inclement weather (SFSP Handbook, Chapter Il) i,~lndoor Meal ~Meal Service [] Other Service I Iwiti Be Cancelled 12 if the site leeds iximarily bemeleas children, what methods are used to ensure that re°neY' f°°d stamps' °r In kind earvicas are nct required t°~ meals? N/A ------ ElY. Ell.. 13 Are meals delivered to the site? IF YES, COMPLETE I~EMS 14, 15, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOI'rOM ' Indicate the means of communication with the vendor which will be used to ad]ual meal deliveries (SFSP Handbook, Chap II) 14 ,.,Site Personnel Will Communicate ,..~ Site p~reannal Will ~ontect .Admlnlab'atlva L~DImoBy With Vendor I~staff, Who Wilt Contact Vanaor ~"'~Ye, []No Will delivery be within one hour of the tood serwca per,od? (SFSP Handbook, Chapter ti) 15 if no, descflbe alTangemante within standm, ds prescribed by local bealth autberlhes for delivery and h°ldlng °f meals until time °f sewlce 16 if tbere b an excess of meals delivered, meals wlll be (SFSPHandbeok, Chaptertil) [.~Stored In Refdgeretor r_lThrown Away ..-, Returned to Vendor - and San~cl tbe Next DaY i lattheSite I Ilor Olapoeal ~he~_ knowled · I certify that this site h~ been visited and that It e information on this form is t?e and correct to the beat of my dren ant~ amd I know that deliberate misrepresentation or ~CasEthRTelceFceYp~l~l~lt~ and ,actiities for the meal serv,ca planned for the number °f chi' P withholding of information may result in prosecubon under applicable state end federal at?"''~" '1 ~ ~ City of Denton  "~O~'~m~~ Su emm r Food Coordinator SUMMER FOOD SERVICE PROGRAM FOR CHILDREN " FOR DHS USE ONLY SITE INFORMATION ~ Civic Center Park ~Ki,nn.e . ~ Denton TX 76201 ATTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED -- ~ ~ ~ Residential Csmp Site Sapping Primarily Migrant Children ~ Other Site 1 Indicate Type of Site I I A.(servlng one to four meals) [] C (sepplng one to four meals) I~l E (serving one to four meals) ] Nonrasldentlal Camp r'-i Site Sewing Primarily Home ess Children B (serving one to four meals) r I D (serving one to four meals) 2 Ust ALL COUnties served by this site Denton 3 A Is your site open r""~]Yes [:::]No B Is your s{te enrolled? []Yes [] No C Site Eligibility Enter Ihs patron!age of children eligible for free and/or reduced pdce meals for the s~te (SFSP Handbook, Chapter II) 22 % D if open sites, submit documentation supporting this percentage figure (such as census date, school data) For open sites using school data, list the schools used to document rote eligibility, attach formula used by school dist to est~bhsh percentage of free & reduced pdce children E For enrolled s~tps, Form 1531 will be used to document eligibility If the enrolled site used school data, list the school used to document the site F What la the percentage of free or reduced-price meals for the site? ! O0 % 4 Did the site participate In previous years' SFSP? (SFSP Handbook, Chapter II) [-~]Yea •No If Yes, give name of oontra~ng organization City of Denton 5 ,Monitoring Plan (SFSP Handbook, Chapter itl) Enter date of moratoring review to be conducted w~thin 6/12/~ I 7/!7/96 6 Meal Service Period Information SFSP Handbook, Chapter II) Breakfast A M Supplement Lunch 40 12.00 P,m~ [.00 P M ~llnnl~F/I Supper 7 Do you plan to feed children under one (1) year old? []Yes [] No 8 Method of Food Predaration by Contracbng Organization (SFSP Handbook Chapter II) ISelf p..~:-.~!~n Ve~ed Using School ,_, Using Fced Seppics Management Ualdg Private Non Profit . [:] On Site [] Central Kitchen [] Food Aulhorlty II Company Ilncludea All Year Contracts) [] O~i~=~,;;on that Is Self-Prep 9 Indicate the system to be used for the serving of meals and the supervimon ct children during meal serv[ce period (SFSP Handbook Chapter II) [~Calcteda-sfyle r-~ Children are Seated ~ Children Line Up Meal Service J I and are Given Meals IZ.I and Pick Up Meals [] Other 10 Est site personnel who will be involved to any extent in the meal service (SFSP Handbook, Chapter II) Site Supervisor 1 Supervise and assist distribution of meals, monitor and maintain meal temperature, site clean-up and other duties as assigned 11 Indicate what provisions will be made tor meal service dunng penods of inclement weather (SFSP Handbook, Chapter ti) [~lndoor Meal ~Meal Service Sewlce L_J Will Be Cancelled [:~ Other 12 ff the site feeds primarily homeless chddren, what methods ers used to ensure that m°fleY' f°°d stamps' °r in Idnd sef~lces sro not raqulrsd f°r meals? 13 Are meals delivered to the site? tF YES, COMPLETE ITEMS; 14, 15, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICA?ION AT Bo'FroM 14 Indicate tho means of communication with the vendor which wdl be used to adjust meal deliveries (SFSP Handbook, Chap II) ,.-,,Site peremmel Witl Communicate ,,.~$ite Personnel Will Contact Administrative lIOIrectiy With Vendor L~ Steff, Who Will Contact Vendor 15 Will delivery be within oce hour of the food service period? (SFSP Handb°°k' Chapter ti) If no, describe anmngemente within standards presc~bed by local health authonites for delivery and holding of meals until time of set'vice 16 if there is an excass of meals beliversd, meals wlll be (SFSPHandbeok, Chapter ill) [.~ Stored In Refrigerator r,..tThrown Away ~Returned to Vendor and Sewnd the Next DaY I lattheSite L._l for Disposal knowted · I certify that this site has been visited and that It ,-,,=o-r ,.m/th.t the nforrnation on this form is true and con'ect ~ the _be~s_t.of,m..~Y.,~..n an~g~nated I know that deliberate mmreprasentatlon or h,,~ she canabilitv and facliibes for the meal serv p ...... ,- -tate and lederal statutes withholding el inlorITTaeufl may ,0,~ ...... r · ~ Ctt of Denton ~ Approved [--'l]Denlnd, rsas°n - --------'-----'---~ ACLU OF VIRGINIA FAX SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR OHS USE ONLY SITE INFORMATION MLK Recreation Center /~clreu ol Slfe ~ (817) 566~-8125 1300 Wilson Denton, TX 76205 From 5/28/96 thmu h 8/9/96 ~ngDaya 4 20 7 A~ACH A MAP W~H ~E SI~ SERVICE AREA IDENTIFIED ~ Residential Comp Site Seining P~ma~ly ~lgmnt Ch dron ~ Other Sits I Indl~te Ty~ of Site ~ ~ (~mlng ooe te foot meals) ~ C (seining ene te four meals) ~ E (se~i~g ene te four meals) ~ Nenmsi~e~t~l Camp S~e ~wlng P~marl~ Homele~ ~ (sewing ooe te four m~ls) ~ D (se~ing ooe t~ roar maals) 2 ~st ALL ~oo~es sewed by ~is site Denton 3 A is your site open ~Yes ~ No B Is yoursite e~miled? ~Yes ~No C 81~ Eliglblli~ ENer ~e ~n~ge of ~lldren ehg~b/e for fr~ anWor ~u~ pd~ meals for ~e rote (SFSP Hand.k, Chapter II) 31 D If o~n s~es, submit d~umenteUoo supposing this ~ntege figure (such as ~nsus date, school data) For o~n sites umng s~l data, Iht ~e s~ls used ~ dormant site elig~blli~, a~ fo~ula used by ~h~l dmt to establmh per~n~ge of free & r~u~ pH~ ~ildren Census data from TAC~ E For anmlled sites, Form 1531 will be used to documant eligibility If the enrolled site used school date, list the school used to documant the site F What is the peroontege of free or reduced-price meals for the site? 100 4 Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter II) F':~'IYee [::]No If Yes, give name of contracting organization City of De~Lon 5 Monitoring Plan (SFSP Handbook, Chapter III) Enter date of monitoring review to be conducted within I 5/3 /96 6/ 2/96 / 7/96 6 Meal Service Period Information SFSP Handbook, Chapter II) Breakfast A M Supplement Lunch 90 [2 P.m. 1.OR P M Supplement Supper 7 Do you plan to feed children under one (1) year old? [] Yes [] No 8 Method of Food Preparation by Contracting Orgamzat~on (SFSP Handbook, Chapter II) I Self r~,..-;-.~-, Vende~ Using School ~ Using Food Service Management Using Private Non Profit [ [] 0;~ Site [] Central Kitchen [TJ Food Authority II Company {Includes Ail Year Contracts) ~] O~¥aiib. allco that la Self-Prep I 9 Indicate the system to be used for the sewing of meals end the supervmmn of chddren during meal service benod (SFSP Handbook, Chapter II) ]Cafeteria-style ~ Children ars Seated r-"l Children Line Up Meal Servl~e Il end sm Given Meals I~l and Pick Up Meals [] Other 10 List site personnel who will be involved to any extent m the meal service (SFSP Handbook, Chapter II) Site Supervisor 1 Supervise and assist distribution of meals, monitor ~ ~ and maintain meal temperature, site clean-up, and other duties as assigned 1 Assist Supervisor ---------- S~te Helper/Server 11 Indioate what provimons will be made for meal serwce dunng penods of inclement weather (SFSP Handbook, Chapter ti) r.~llndoor Meal ,.--~ Meat Sewlce ~wl~ IiWill Be Cansalisd [] Other 12 ff the site leeds primarily bemeless children, what methods are used to ensure that re°neY' t°°d stamps' °r in kind services are nct mClUlred f°r meals? N/A --'-'------ [~]Yaa [].o 13 ~re mens delivered to the site? IF YES, COMPLETE ITEMS 14, 15, & 16 IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM 14 Incllcate the means of communication w~th the vendor which will be used to adjust meal dalivanes (SFSP Handbook, ChaP ti) ,...~ Site personnel Will Communi~.,ate ,.-.~S~ pemonnel Will Contact .Administrative LJ Directly With Vendor L~ ~t~ff, Who Will Con.ct Vanaor EIb' [].o 15 Wlll dal~ve~ybe within °ne h°ur °f the Icad service peri°d? (SFSP Handbe°k' Chapter II) If no, describe a~angements within standards prescribed by local health autbenties tor dahvory and holding of meats until time of 18 ilthamlsanexcessofmeaisdellvored, maals will be (SFSPHandbook, Chaptertil) r~..~Stered In Refdgamter r_lThmwn Away ,...~ Returned to Vendor and Seared the Next Day I let the Site L.J for Disposal []Other' I CERTIFY that the Information on this form is true and correct to the beet of my knowledge I cattily that this site has been visited and that tt has the cabeblllty and facitlUes for the meal service planned for the number of children antic~pated I know that deliberate misrepresentation or withholding of information may result in prosanut~on under applicable state and federal _et_~_tlitnS ~ ~_ o~~ "-City°f Dent°n umme r Food Co~ ACLU OF VIRGINIA FAX SUMMER FOOD SERVICE PROGRAM AGREEMENT City of Denton STATE OF TEXAS § COUNTY OF TRAVIS § The Texas Department of Human Services, hereinafter referred to as TDHS, AND hereinafter referred to as the contractor, do hereby make and enter mto thts contract, as requtred by the Nattonal School Lunch Act (Section 13) and the Sununer Food Set'vice Program, hereafter referred to as the SFSP, Federal Regulattons (7 Code of Federal Regulattons [CFR], Part 225) I MUTUAL AGREEMENTS The Part~ea mutually agree A If, the contractor fads to prowde serv~cas m accordance with the provts~ons of thts contract, the DeparUnant may, upon wrttten nottce of default to the contractor, tmmedtately terminate the whole or any pan of this contract and refuse to pay claims for reimbursement Such termination and/or refusal to pay claims for reimbursement shall not be exeluswe remedy but shall be m addition to any other rights and remedies prowded by law or under this contract B If federal and state laws or other requirements are amended or judtclally Interpreted so that the eoutmued fulfillment of thts contract, on the pan of e~her party, ts subs~tamtally unreasonable or impossible, or if the pan,es are unable to agree upon any amendment whteh would therefore be needed to enable the substanual contmuanon of the services contemplated by th~s contract, then the parties shall be dtscharged from any further obhgauons created under ;he terms of thts contract, except for the equitable settlement of the respeeuve accrued interest or obligations, meluthng autht findings, recurred up to the date of termmatton C This contract may be canceled by mutual consent However, tf such mutual consent cannot be attamed, then and tn that event, etther party to th~s contract may constder tt to be canceled wtthout cause by gwmg thtrty (30) days nouce tn writing to the other party and thts contract shall thereupon be canceled upon the exptrat~on of such thtrty (30) day period Nothtng m this paragraph shall be construed to proh;btt tmmedtate cancellauon pursuant to above paragraphs A and/or B Il CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT A The contractor wdl comply with the SFSP Federal Regulations (7 CFR, Part 225, as amended), Uniform Federal Assistance Regulation (7 CFR, Part 3015, as amended), and state pohcies and procedures as ~ssued and amended by TDHS The contractor further agrees to perform as descr,bed tn ~ts apphcauon (including supporting documents and approved amendments to the apphcatlon) for participation in the SFSP B The contractor accepts final administrative and financial responslbthty for food service operations at each site sponsored by the contractor This r~aponsibillty includes the peffonnance of, the condmon$: og ~*tlement,of~.lmy audit,exceptions or payment deficiency in the program and the collection and repayment of any amount paid in excess of the proper claim amount which are found after momtormg or auditing by TDHg or the United States Department of Agriculture (USDA) This responsibility applies to this contract, and all subcontracts hereunder C The contractor will apply to TDHS for approval of changes to its original applt~tion and for prior author,zation for field trips if meals served on the field trtps will be clatmed for reimbursement Requests for changes and field trip authorization must be received by TDHS at least five (5) calendar days before the requested effective date for the change or the field trip Contractors will noufy TDHS within five (5) days of the termination of an approved food service site IlL SFSP RECORD KRRPING A The contractor will keep financial and supporting documents, statistical re, gords, and any other records pertarmng to the services for wMch a claim ~s subnutted The records and documents will be kept for at least three (3) years and ninety (90) days aRer the termmaUon of the contract period If any litigation, claim, or audit revolving the~e records begins before the stipulated time period exp,res, the contractor will keep the records and documents for not less than three (3) years and mnety (90) days aRer the termmaUon of the contract period and untd all hugation, claims or audit findings are resolved The case ~s considered resolved- when a final order is issued m lmgaUon or a written agreement ~s signed by TDH$ and the contractor Extensions are considered as separate contract periods B The contractor and its subcontractors will allow TDHS and USDA officials and other appropriate officials deterrmned by TDHS to respect facdmes and records and to audit, examine, and copy records at any reasonable time This includes access to all records of costs paid, even in part, by TDH$ Non School Spo~ors Page 2 IV CIVIL RIGHTS POLICY COMPLIANCE A The contractor agrees to comply with Title VI of the Civil R~ghts Act of 1964 (Pubhc Law 88-352), and all reqmrements imposed by the regulations of the Department of Agriculture (7 CFR, Parts 15, 15a and 15b) Department of Justice (28 CFR, Par~s 42 and 50) and USDA and TDHS directives or regulations issued pursuant to that Act or the regulations, Section 504 of the Rehabilitation Act of 1973 (Public Law 93-112), The Americans with Dssablhties Act of 1990 (Public Law 101-336), and all amendments to each, and all requirements imposed by the regulations issued pursuant to these acts In addition, the contractor agrees to comply with Title 40, Chapter 73, of the Texas AdmmastraUve.. Code These provide in part that no persons in the Untied States shall, on the grounds of race, color, national origin, sex, age, disability, political beliefs or religion be excluded trom partm~patlon in, or denied, any aid, care, service or other benefits provided by federal and/or state funding, or otherwise be subjected to discrimination under any program or activity for wMch the contractor receives federal financial assistance from TDHS and USDA and hereby gives assurance that it will munedlately take any measures necessary to effectuate this agreement B Tho contractor agrees to comply with Texas Revised Civil Statutes Amcle 4419b-4, Sections 5 03 and $ 04 (relating to workplace and confidentiality guidelines regarding AIDS and HIV) C This assurance is given in consideration of and for the purpose of obtaining any and all federal financial assistance, grants and loans of federal fund, reimbursable expenditures, grant or~ donation of federal property or interest in such property, the detail of federal personnel, the sale and lease of, and the permission to use, federal property or interest in such property or the filrnlshlng of services without consideration or at a nominal consideration, or at a consideration which is reduced for the purpose of assisting the recipient, or m recognition of the pobh¢ interest to be served by such sale, lease or furmshmg of services to the recipient, or any improvements made with federal financial assistance extended to the contractor by TDI-IS This includes any federal agreement, arrangement, or other contract which has as one of~lts purposes the provision of assistance such as food, cash assistance for the purchase of food, rental of food service equipment or any other financial assistance extended in rehanee on the representation and agreements made in this assurance D This assurance is binding on the contractor, its successors, transferees, and assignees as long as It receives assistance or retains possession of any assistance fi.om TDHS or USDA~ The person whose signature appears ou this contract ss authorized to make this assurance on behalf of the contractor V TDHS CLAIMS PAYMENT TDHS will, subject to the federal appropriation and avaflabthty to TDHS of sufficient funds for the SFSP, make program payments to the contractor in accordance with the terms of this contract No reimbursement shall be made for performance under th,s contract occurring prmr to (a) the beginning effective date of this contract or Co) a later date estabhshed by TDH$ based on the date of receipt of a fully executed copy of this contract Non School Sponsors Page Vl CERTIFICATIONS A Immigration Reform and Control Act of 1986 - The contractor agrees to comply with the reqmrements of the Immigration Reform and Control Act of 1986 regarding employment venficatton and retention of vermficauon forms for any mdmwduals Mrod afxer November 6, 1986, who wdl perform any labor or servmces under thins contract B Regarding Debarment, Suspension, Inehgmbfl~ty, or Volontardy Exclusion For Covered Contracts - The contractor certmfiea, by executmon of this agreement, that neither It nor mrs prmcmpals ~s presently debarred, suspended, proposed for debazment, declared mehgible, or voluntardy excluded from partmcmpatmg m this contract by any federal department or agency or by the State of Texas By making thla eemficauon the contractor agrees to the following terms I The above cert~fication ms a material representat,on of fact upon which reltance was placed when thins contract was entered Into If It Is later determined that the contractor knowingly rendered an erroneous certmficatmon, m addltmon to other remedies available to the federal government, the Depa~meut of Health and Human Services, United States Department of Agriculture or other federal department or agency, or the Texas Department of Human Services may pursue available remedies, including suspension and/or debarment 2 The contractor shall provide immediate written notice to the person to which this certlficatmon ms submitted If at any time the contractor learns that the eertlfie, atmon was erroneous when submmRed or has become erroneous by reason of changed circumstances 3 The words "covered contract,' 'debarred," "suspended," "mehglble,' "parttclpant," "person," 'principal," "proposal," and 'voluntarily excluded," as used in this certification have meanings based upon materials m the Definmons and Coverage secttons of federal rules Implementing Executive Order 12549 Usage ts as defined m the attachment 4 The contractor agrees by submitting this certification that, should the proposed covered contract be entered mnto, mt shall not knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation m this covered transaction, unless anthonzed by the Department of Health and Human Services, United States Department of Agriculture or other federal deparUnent or agency, a~d/or the Texas Department of Human Servmces, as applicable 5 The contractor further agrees by submmttmg thins certification that it will include TDHS Form 2046 tmtled "Certmfication Regarding Debarment, Suspension, lnehglbdtty, and Voluntary Exclusion for Covered Contracts" without modification, mn all covered subcontracts and mn sohcltatmons for all covered subcontracts 6 A contractor may rely upon a cemficaUon of a subcontractor that is not debarred, suspended, meh§lble, or voluntarily excluded fi.om the covered contract, unless tt knows that the cemficatmon ms erroneous A contractor must, at a minimum, obtain certifications from Its covered subcontractors upon each subcontract's initiation and upon oath renewal Non School Sponsors Page 4 CERTIFICATIONS (continued) 7 Nothing conta,ned m all the foregoing shall be construed to require estabhshment of a system of records m order to render tn good fa,th the cert~ficanon requtred by this cert,ficat~on document The knowledge and reformat,on of a contractor ,s not requ:red to exceed that which ~s normally possessed by a prudent person m the ordinary course of business dealings 8 Except for contracts authortzed under paragraph 4 of these terms, ~f a contractor m a covered contract knowingly enters Into a covered subcontract w~th a person who ,s suspended, debarred, mehg,ble, or voluntarily excluded from part,c,pat,on m th~s transact,on, m add,tlon to other remedies available to the federal government, Department of Health and Human Services, Umted States Department of Agriculture, or other federal department or agency, as applicable, and/or the Texas Department of Human Serv,ces may pursue available remed,es, including suspension and/or debarment C Regarthng Federal Lobbying - Th,s cort,ficat,on apphes only to this contract and ,s a mater,al representat,on of fact upon whteh reliance was placed when th,s transact,on was made or entered mto Subm,ss,on of this certification ,s a prereqms,te for making or entering into th,s transaction unposed by seet,on 1352, title 31, U S Code Any person who fads to file the required tort,float,on shall be subject to a c,wl penalty of not less than $10,000 and not more than $100,000 for each such failure The contractor tort,ties, to the best of bls or her knowledge and behef, that I No federally appropriated funds have been paM or will be paM, by or on behalf of the undera,gned, to any person for influencing or attempting to Influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress m connection with the awarthng of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, or the extension, contllluatlon, renewal, amendment, or mothficatton of any federal contract, grant, loan, or cooperative agreement 2 If any funds other than federally approprmted funds have been paid or will be paM to any person for influencing or attempting to influence an officer employee of any agency, a member of congress, an officer or employee of Congress, or an employee of a member of Congress In connect,on w,th th,s federally funded contract, subcontract, subgrant, or cooperat,ve agreement, the undersigned shall complete and submit Standard Form-LLL, 'D,sclosure Form to Report Lobbying," tn accordance w,th its mstruct,ons 3 The contractor shall reqmre that the language of thts certtficatton be tncluded tn the award documents for all covered subawards at all tmrs (including subcontracts, subgrants, and contracts under grants, loans, and cooperattve agreements) and that all covered subrec~pmnts shall eert,fy and thsclose accordingly The contractor cert,fies that all mformat~on subm,tted pursuant to th~s agreement Is true and correct The contractor understands that the dehberate m~srepresentatlon or wlthholthng of tnformatton is a violation of thts contract and may result m prosecution under apphcable state and federal statutes Non School Sponsors VII Etq~ECTIVE DATE AND SIGNATURES For the fmthful performance of the terms of thru contract, the part~es hereto m their capaot,es stated, affix their s~gnatures and bind themselves Czty of Denton Name of the Contracting Organization (Please Print or Type) Original s,gnature of the authorized representat,ve of the contracting organmation Ted Benavzdes Name of the author=ed representative of the contracting organization (Please Print or Type) C~ty Manager Title Please print or type, in the spaces provided above, the name and title of the authorized representative signing th,s agreement on behalf of the contracUng organization Rewsed February 1994 School Sponsors Page 6 1996 CONTRACT YEAR Texas Department Form 1569 Of Human Set~ces SPECIAL NUTRITION PROGRAMS November 190S SINGLE AUDIT IDENTIFICATION DATA Clty of Denton Teresa Milam Address (SIzeet or P O BOX Cily State ZJP) 321 E. McKlnney Denton, Texas 76201 Telephone(817 No) 566--8125 17560005146013 Con~= No Conlrac~ot09/30/96F,scaJ Yem' Encl (mm/dd/yy) [:::] For Profit [~ Non Profit [~Govemmental Check the appropriate box(es) to indicate the type(s) of program(s) In which you currently participate or for which you are applying [] A - National School Lunch [:~ AD - Adult Day Care [] B - Charitable institutions ~ aL- Nabonal School Lunch/Breakfast [] C - Area Agency on Aging [] CC - CACFP Canter [] G - Summer Camps [] DH - CACFP Day Home [] H - Summer Food Service [] SF- Summer Food [] J - Jarls [] SM - Special Milk [] K - Soup Kitchen [] TE- TEFAP [] I - TEFAP Commodities Give the source and amount of any federal financial assistance that your agency receives other than from those programs listed above $~e ~ttached :::]SINGLE AUDIT EXEMPTION--I certdy that I am not required to submit an audit under the S~ngle Audit Act for the folFowmg reason(s) I [] i am a for. profit organization ["~ [ receive leas than $25,000 annually in total federal funding '-~ r~ SINGLE AUDIT ASSURANCE-I understand that ~f I meet the requirements of the Single Audd Act, I will agree to submit [] An Annual [] A Blenmal audit as a conddmn of ehg~bfl~ty to pa~c~p~te ~n the Specml Nutrlbon Programs and that failure to do so as required could result tn adverse action, including the w~thboldmu of my claim for reimbursement payments and termmaUon of my contract I also understand that if I am a private non proflt orgarszat~on subleCt to the reqmrements of the Single Audit Act and have a flnancml audit pedormed annually, I must also obtain a s~ngle audd on an annual bas~s ~ ~1~ n'E[tJre.-~uthOltZe~epr eienlal~ve I T,Ite ~¥].e Hog~e $~mmer ~ood Coo~lnetor CERTIFICATE OF AUTHORITY This is to certify that I Fed Benavldes Cl~v M~]~ger ~ S~bn~re--Autho~zed Omc~J IS designated ss the authorized representative of City of Denton 321 East McKlnney Denton, Texas 76201 The representative designated above is authorized on behalf of the contracting organization to make written agree- ments with the Texas Department of Human Services to operate a food program, to sign documents or reports about the agreement, and to present claims for reimbursement, when appropriate, to the department Ted Benav~des City Manager i FOR DEPARTMENT OF HUMAN SERVICES USE ONLY CERTIFICATE OF AUTHORITY This Is to certify that I Teresa Mllam Le~sure Services Manager , Is designated as the authorized representative of City of Denton 321 East McKlnney Denton~ Texas 76201 The representative designated above Is authorized on behalf of the contracting organization to make written agree- ments with the Texas Department of Human Sewlcea to operate a food program, to sign documents or reports about the agreement, and to present claima for reimbursement, when appropriate, to the department Name o~ 0 fr~.~ (Hem~e type m' Ixln~) Ted Benav~ C~ty Manager FOR DEPARTMENT OF HUMAN SERVICES USE ONLY' CERTIFICATE OF AUTHORITY This Is to certify that K¥1e lIogue Summer Food Coordinator I$ designated aa the authorized representative of C~ty of Denton 321 East McKlnne¥ Denton~ Texas 76201 The representative daslgnated above Is authorized on behalf of the contracting organization to make written agree- ments with the Texas Department of Human Services to operate a food program, to sign documents or reports about the agreement, and to present claims for reimbursement, when appropriate, to tho department Name of O.'.~al ~ I,A~e m' ixlm) 'TUe I Ted Benav~des C~ty ManaKer , FOR DEPARTMENT OF HUMAN SERVICES USE ONLY o,..,~. S~vlc.. SUMMER FOOD SERVICE PROGRAM FOR CHILDREN .~.nu.~ CIVIL RIGHTS QUESTIONNAIRE I CIVIL RIGHTS ACT OF 1964 A 1 Estimate, by racial/ethnic group, the number of children that will participate In the program at each site If the program cons;sis of several camp sessions, specify the prolected number of children by site and date of session SITE AMERICAN ALASKAN ASIAN/ PACIFIC aLACK HISPANIC WHITE (name of 811e, a;hool, ©Imp, etc I INDIAN NATIVE ISLANDER Owsle~ Park 20 lb b TWU Clubhouse Pro~ram 10 10 35 Denla Park 10 10 10 Phoenix Park 50 30 10 Civic Center Park 10 10 20 MLK Recreataon Center 60 20 10 Village East Apartments 20 10 20 Rayzor Elementary School 25 100 25 Houston Elementary Sohool 10 10 10 2 Describe howthis projaction was made (is ,based on comparative enrollment m sites, observat~onof students, student aurnames, etc Observataon of neaqhborhoods B Does the organization have spe,~ifle membership requirements which result in the denial of program benefits to specific groups? [] Yea [] No If yes, describe those requirements C ~hate~wi~bem~eWthe~an~n~mnt~min~d~dgrassr~ani~a~nsab~ut~e~pp~tun~part~ci~tsinthepr~ram? Posters dasplayed an nea~hborh~ods, attend communat¥ meet~nos and ~ubllc servace announcements D What other outreach stops will be taken by the organization to ensure that m~normes in the area from which it draws its attendance w.ll have an equal opportunity to participate m the program? S.F.S.Po anformataon wall be pranted ~n spanash E Has any federal agency notified the organization of non~omplmnce w~th the C~vd R,ghts act of 19647 [] Yes [] No If yea g~ve details Including dates, names, and results II REHABILITATION ACT OF 1973 (Section 504) A Does the contracting organization have any pohcies, practices, or arch~tsctural barriers that hmlt, deny, or d~scourage participation in the program or employment by the contracbng orgamzacon because of dmab~hty? [] Yes [] No If yes, explain B Are there any policies or practices that result ~n unequal treatment in the dehvery of benefits or services to parhcipants, apphcante, or employees according to disability? {'-lYes ~""~lNo If Yes, explain C Does the contracting organization employ 15 or more people? [] Yea [] No If yea 1 Enter the name and title of the coordinator who will work w~th DHS to ensure that Section 504 requiramante are mat I N'm~r~ ~ lam T'"eLelsure Services Manaqer I 2 Has the organization established grievance procedures that incorporate appropriate due process standards? [] Yea [] No If yes, do these procedures provide for the prompt and equitable resolution of complaints that allege an action prohibited by Soct~on 504 of the Rehabilitation Act of 19737 [] Yea [] No 3 Has the oontracting organization Informed the public of the right to file a complaint and of the filing procedure? [] Yes [] No If yes, briefly describe how the pubhc was mformeq 'Phere are ~osters and ~lvers .?osted throuqhout the C~ty of Denton wn~cn ac~nowledges the Cltv's compliance with the guldellns set by the EEOC, ADA, and the Clvll Rl.~hts Act. These posters g~ve Instructions for f~llnq a complaint D Has the organizaton taken etebe to notify employees, participants, and applicants that the organization does not d~scr~mtnate on the basle of disab~hty? [] Yes [] No If yes, do the people notified include those with impaired vis~on or heanng and members of unions or professional organizabene holding collective bargaining or profaseiosal agreements w~th the contraotlng organization? [] Yea [] No If yes, brioflydeacribehowtheyerenofifted The visually or hearing zmDazred are notzfzed ~hr~qh radzo and televisIon advertisement. Also flyers, announcements, etc. are mazled E Do all organization forms, publications, and recruitment materials which inform the public of program benefits and employment opportunities contain the assurance that the orgamzat~ondoea not dmorlminate on the basis of disability? [] Yea [] Ne If no, indicate steps being taken to comply with this requirement F Does the organization have a procedure to ensure that t~e remed=al or correchve action has been or will be taken if non-compilenco with non dlecflmtnalton requirements ,s found by DHS, USDA, or the contracting organization itself? [] Yea [] No Ityas, explam If not handled w~th~n the department ~n question, the C~ty g~n~rally channels ~11 complaints through the Legal Department. PUBLIC SERVICE ~ FO~, ~ S~TES The Denton Parks and Recreation Department announces the sponsorstup of the 1996 Summer Food Service Program Meals will be prowded at the saes hsted People who are ehg~ble to panic,pate m the program must not be dtscnrmnated against because of race, color, nauonal origin, sex, age, d~sabthty, rehg~on, or pohucal behef Anyone who bel, eves that they have been d~scnmmated agmnst should write tmmedtately to Dtrector, C~wl Baghts D~vmon, MC-106, Texas Department of Human Services, P O Box 149030, Austin, Texas 78714-9030 or the Secretary of Agriculture, Wastungton, D C 20250 Note l~scnnunaUon complaints based on rehg~on or polmcal behefs must be referred only to the D~rector, Ctwl Raghts D~ws~on, Texas Department of Human Serwces Dates S~tes Address Ttme May 28-Aug 9 C~v~c Center Park 321 E McI~nney 12pm-lpm May 28-Aug 9 Dema Park 1001 Parwn 12pm- I pm May 28-Aug 9 MLK Rec Center 1300 Wilson 12pm- I pm May 28-Aug 9 Owsley Neighborhood Stella St 12pm-lpm May 28-Aug 9 Phoemx Park 308 S Ruddell 12pm-lpm May 28-Aug 9 TWU Playhouse Program Mary Hufford Court 12pm-lpm May 28-Aug 9 Village East Apartments 1700 Vtllage East 12pm-lpm PUBLIC ~ ANNOUNCEMENT FOR THE ~ SITE The Denton Parks and Recreation Depa~ment announces the sponsorstup of the 1996 Summer Food Service Program Income Ehg~bd~ wtll be based on farmly size and income using the Standards for Detemumng Free and Reduced-Price Eh~bihty, provided by the Umted States Department of Agriculture Meals w~ll be provided at the site hsted People who are ehg~ble to partmlpate in the program must not be discriminated against because of race, color, national origin, sex, age, dlsabdlty, rehg~on, or pohtlcal behef Anyone who beheves that they have been d~scnn~nated against should write m~me&ately to D~rector, Civil P~ghts Division, MC-106, Texas Department of Human Seonces, P O Box 149030, Austin, Texas 78714-90:30 or the Secretary of Agriculture, Washington, D C 20250 Note Discnnunat~on complaints based on rehg~on or pohtlcal beliefs must be referred only to the Director, Civil P~ghts D~wsion, Texas Department of Human Serwces Dates Sites Address Time June 3-28 Houston Elementary 3100 Teasley Lane 11 45am-12 45pm June 3-28 Rayzor Elementary 1400 Malone 11 30am-12 30pm ***NOTICE*** The 1996 Summer Food Service Program is sponsored by the City of Denton, Parks and Recreation Department, and is offered through a federal grant which requires that sponsors apply each year to retain eligibility to offer the program. It is therefore, our declaration that the SFSP will be offered this summer, from May 28th through August 9th, strictly as a PILOT PROGRAM, and that the City of Denton PARD, is in no way directly liable or responsible for the continuance of the program in the future. 8UMBER FOOD ~ERVICE I~OORAM ~UDGET 1~ p~ St~ ~e H~ ~2~e L~ 6 t5 ~ 76 t3 376 ~ ~ 0 0785 ~ 4236 18 ~ C~ ~e 0 0234 ~ 672 85 325 53 tl 55 t26 698 75 Tr~ ~ 53 0 ~ t~5 ~ **Difference of $1.85 is due to rQur~i~g ~,, ..~ SUMMER FOOD SERVICE PROGRAM APPROVAL DOCUMENTS SFSP Agreement ~ 1 Retain for your a~;enc,es SFSP files 1506 Apphcatlon for Participation, A, B, I 1 Retain for your agencies SFSP files 1507 S~t~ Information I Retain for ~(our avenmes SFSP files PROGRAM OPERATIONS FORMS IIIIII IIII 1513 Claim for Reimbursement 4 Submit completed claims to Fmanc,al Serwces, Y-906 1514 Claim for Reimbursement 4 Complete for each claim subm,tted Worksheet Retain on file 1557 Momtonng S~te Review (Vended 3 Complete one form per s~te Sponsor Programs) maintains forms for rewew by TDHS and USDA 1558 Momtonng S~te (On-Site 3 Complete one form per s~te Sponsor Preparation) maintains form for rewew by TDHS and USDA 1566 Momtonng Program 3 Completion required Sponsor maintains form for rewew by TDHS and USDA 1568 Re(~ord of Recycled Food 3 Completion required Sponsor maintains forms for rewew by TDHS and USDA 1601 Beneficiary Ethmc~ty Data 3 Completion required Completed form maintained by sponsor C~vll R~ght Posters "And Justice 1 poster of Required posting of all 3 posters at for,All", L~berty Bell - Enghsh, each per s~te each s~te L~berty Bell - Spamsh We~kly Call-In Report, 16 Completion required Worksheet Follow enclosed instructions Submit or make verbal report to Financial Serwces Budget Amendment 3 Submit to contract manager pnor to s~gmflcant changes ~n budgeted cost SUMMER FOOD SERVICE PROGRAM APPROVAL DOCUMENTS Page Two ADDITIONAL FORMS FOR ENROLLED PROGRAMS ONLY 1513 Claim for Reimbursement for Camp 4 Submit completed cia,ms to F,nanc,al Attach- Enrollment Report Serwces, Y-906 (Required form for ment A Camp Enrollment only ) 1531 Child Nutrition Program Apphcat~on 2 Retain for use (Enrolled Programs Only ) 1625 Letter to Parents (Charge 2 Retain for use (Enrolled Programs Separately) Only ) 1625-A Income Standards for Determining 2 Retain for use (Enrolled Programs Child Nutnt~on Program Ehg~b~hty Only ) 1626 Letter to Parents 2 Retain for use (Enrolled Programs Only ) 4504 Standards for Determining Free 2 Retain for use (Enrolled Programs Reduced-Pnce Ehg~b~hty (for Only ) Fac~hty Use) PROGRAM REFERENCE DOCUMENTS ....................... Contract Appeals, Fair Hearing, 1 Reference mformat~on regarding Fraud, and Ctwl R~ghts procedures for Contract Appeals Pohcy Alert SFSP 96-3 1 Reference for your ~nformat~on S~ngle Audit Documentation and use and Compliance Requirement Pohcy Alert SFSP 96-4 1 Reference for your ~nformat~on SFSP Reimbursement and use FY96