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1995-101
A: \ SUNR~ER. SER ~- ~ ~ ORdINANCe. NO. 101 AN ORDINANCE OF THE CITY OF DENTON, TEXAS, AUTHORIZING THE CITY MANAGER TO EXECUTE ALL DOCUMENTS AND AGREEMENTS, AS REQUIRED, TO OBTAIN FUNDING FOR THE 1995 SUMMER FOOD SERVICE PROGRAM; AUTHORIZING THE EXPENDITURE OF FUNDS TO ADMINISTER THE PROGRAM; AND PROVIDING AN EFFECTIVE DATE. WHEREAS, the City of Denton, Texas will submit an application for funding under the National School Lunch Act, to the Texas De- partment of Human Services for the purpose of making meals avail- able to eligible children at the City's Summer Action Site pro- grams; and WHEREAS, pursuant to the grant, if received, the City will con- tract with the Denton Independent School District to provide the meals at the various sites; NOW, THEREFORE, THE COUNCIL OF THE CITY OF DENTON HEREBY RESOLVES: SECTION I. That the City Manager is hereby authorized to execute, on behalf of the City, an application for funding under the National School Lunch Act, and if funded, the Summer Food Ser- vice Program Agreement with the Texas Department of Human Services, a copy of which is attached hereto and incorporated by reference herein. SECTION II. That the City Manager is hereby authorized to execute a contract with the Denton Independent School District to provide meals for eligible individuals at the various sites, and such certifications as are necessary to carry out the 1995 Food Service Program, and to handle all fiscal and administrative matters relating to the application and the program. SECTION III. That the expenditure of funds necessary to administer the 1995 Summer Food Service Program is hereby authorized. SECTION IV. That this ordinance shall become effective immed- iately upon its passage and approval. PASSED AND APPROVED this the /~day of ~ , 1995. BOB CASTLEBERRY, MAYOR / ~ / 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 District and the ~. Denton Ind _epeml__~t School District agrees to supply unitized meals inclusive of milk and juice to the City_ of Denton Parks and Recreation Department, at the MLK Recreation Center, Phoenix Park, Denia Park, Civic Center Park, Owsley Neighborhood, TWU Playhouse Program, Village East Apartments, Rivera Elementary Summer School, and Wilson Elementary Summer School, with and for the rates herein listed: Breakfasts ...... $ 0.00 each Lunches ........ $ 1.50_each Snacks .......... $ 0.00 each Supper ......... $ 0.00 each It is further agreed that the Denton Independent School District, pursuant to the provisions of the Summer Food Service Program Regulations, a copy of which is attached as Exhibit "A" and is part of this agreement, will assure that said meals meet the minimum requirements as to nutritive value and content as outlined in the U.S.D.P~'s Sponsor Meal Preparation Handbook, and will maintain full and accurate recordings of such, including the following: 1. Menu Records, including amount of food prepared. 2. Meals, including dally 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 retain records required under the preceding clause for a pedod of three years and 90 days after the end of the fiscal year to which they pertain (or longer, if an audit or litigation is in progress); and upon request, to make all accounts and records pertaining to the program available to representatives of the U.S. Department of Agriculture and the General Accounting Office for audit or administrative review at a reasonable time and place. The Denton ~d_~pendent School District agrees to comply with the requirements of the Immigration Reform Control Act of 1986 regarding employment verification and retention of verification forms for any individuals hired after November 6, 1986 who will perfoiiii labor or services under this contract. The agreement shall be effective as of~. It may be terminated by notice in writing given by any party hereto to the other parties at least 30 days prior to the date of termination. IN WITNESS WHEREOF, the parties hereto have executed this agreement as of the dates indicated below: Agro~.d to this date /~/LC/l(C,/q~-~/ , A~e~tot~sdate 4-25-95 Spon~r O~ci~ Sch°°l Sp°n~r ~~ ~ ~ Title Ci~M~ager ~ Title DISD School Board President , Dui~u~¢ Fo~m 1~0~/' ~,an Son,cas SUMMER FOOD SERVICE PROGRAM FOrt OHS STAFF ONLY APPLICATION FOR PARTICIPATION ~x,o. IL,. c~, ~ I NOTE: Give as much Information as possible. Attach additional sheets If needed; r--]Btealdast [] A.M. Supp. [] Lunch please Identi~y each attachment with the name of the contracting organization. [] P.M. Supp. [] Supper [] All CTION I-SPONSOR INFORMATION [rac/J~ O~'ganJzalJ~l Name Vendor IO NO. i ~elephone NO. Ho{line NO. City of Denton 17560005146015 . 817 ) 566-8125 (817) 566-8125 ng Add~es$ (S, Uee! m' P.O. Box, City, State, ZIP) 321 E. McKinney Denton, Texas 76201 .,~! Addi'esa ~ 3'ilia -~o ~ Am~.~.~ Children' s Programs Supervisor Brenda Burton .'ontractoY Classification (Check all that apply): r--i Academic Year National Unit of Government-Contractor certifies that all local ~ National Youth Sports Program II Youth Sports Program F~ service sites am operated directly by the contractor. g--t Residential/Nonresidential Continuous Calendar ~ School Food Authority I I Summer Camp ['-] School Year ~1 Private Non-profit s your program a year-round program? ................................................................................... ~-~Yes ~ No Type of Contractor: -"[-'-J Public Entity (explain): City Agency is your agency considered to be state owned/operated? .................................................................... [-'-'] Yes [] No Do you deposit your program reimbursement directly into the State Treasury? ........................................ ~-~ N/A [--] Yes [] Ho DO you deposit your program reimbursement If yes, is it direct deposit? ................................................................................. j-]Yes J--]No ~ Private Nonprofit Organization-Tax-exempt status established. AItach letter of determination (iRS 501-30) of tax-exempt status from IRS. ldo you deposit your program reimbursement into a local bank? ................................................... ~ N/A j--] Yes J--J No II yes, is il direct deposit? ........................................................................................ j--J Yes ~oes the organization provide an ongoing year-round service to the community that Js to be served by · ",e Summer Food Service Program (SFSP)? ........................................................................ J~Yes J---j Ho : no, which of the following circumstances applies? --] Residential Camp ['-] Failure to operate would deny program to a poor area '--'] Serves Migrant Children [] Failure to operate would deny a significant number of children access to program Does [he organization receive $100,000 or more in federal funds yearly? ................................................. ['X'] Yes [] Does the organization receive more than $25.000 but less than $100,000 in iederal funds yearly? ....................... ~"-]Yes [] No : Attach a copy of the audit covering last year's program operation or documentation that an audit conforming with SFSP policy will be conducted, including the date it will be conducted. Fo~m I.~0~ P~g~ 3 re children charged separately Ior meals? ........ ' ........................................................................ ["-]Yes [~'~No yes, see Form 1508, Attachment B, }o you want to receive advance payments? ................................................................................ r-'l Yea [] No yes, 1. For Operational Costs? .......................................................................................... ['*'-]Yes [-"~ No 2. For Administrative Costs? ......................................................................................... ['-']Yes [] No meal service Is self-preparation, do you want to receive commodities? ................................................... ~'lYes [] No yes, Fon~ 1608, Applical/on and Agreement for Commodities, must be completed. ;TION IV-PROGRAM OPERATION Beginning and Ending Dates of Meal Service: From ICmy 30, 1995 through August 11, 1995 Number of sites: .......................................................................................................... 9 st dates and topics ol SFSP training: DATES TOPICS 5/25/95 Site supervisor and monitor training on S.F.S.P. guidelines the organization planning to contract with a food service management company r the preparation of unitized meals? ................................................................................... l lYes I~} No yes, and the contract will exceed $10,000, attach a copy of the invitaticn to bid. Also give: a~e of Bid PublicalJon Place o! Pub/icalion Date o! Bid Open,no T~ne ol B~d Opening ~ b~d expected to be $ 100,0OO or moro? If yes, g~ve place ol b~d opening: ©Y,s I-].o '3, altach a copy of an 11-day-cycle menu including alt specific menus to be used. the organization contracting with a year-round food service management company? ..................................... [--"]Yes ~ No fas, submit a copy of your procurement procedures, bid, contract, and all amendments. ~ch a copy of the letter which has been (or w~ll be) sent by the orgamzation to the Health Department notifying them of intent to operate :od Service Program at the site(s) indicated on the attached Site Information sheet (Form 1507). ;TtON V-ASSURANCES 'ee Meal Policy Statement The contracting organization assures the Texas Department of Human Services (DHS) that all children at the sites described on the Site(s) Inlormation Sheets Ior the Summer Food Service Program, wtll be offered the same meals with no physical segregation of, or other discrimination against, any child because of race, color, disability, age, sex, national origin, religion, or political beliels. No separate charge w~ll be made for any meal except in accordance with attachment B of this application. The contracting organization assures DHS that, ~f it ~s sponsoring camps or other enrollment programs: · The contracting organization has or wilt obtain family raze and ~ncome data about all children whose meals w~ll be reporled as bee or reduced-price; and · The children claimed as free or reduced-price meet the current famdy size and income standards set by the United States Department ol Agriculture, DHS Form 4504, Standards for Determining Free and Reduced-Price Eligibility. :uosea.~ 'peluep il O31N3OF-'1 a3AOaddVr-] A'INO 3S1'~ $Ha ao~ · sainlelS leJepeJ pue ellis alqeotldd~ Japun UOtlnoesoJd Ul llnseJ Xem UOllgmJoju( ~Ul~oqq~6 UOllelueseJd~m elgJeqlleP 1~1 ~ou~ I 'Sells pe~oJdde 1~ e=uepue11~ ul eJ~ ~e~l sJno~ e~l 5ulJnp ueJPll~ elql611e ol ~es Sl~e~ pe~oJdda ~oj ~lUO eq IIi~ lue~esJnq~leJ 1~1 ~ll~e= I 'e6Pel~ou~ ~ jo lSeq e~l ol l=eJJo3 pue eh Jl si UOlleOlldd~ Sl~t uo uoll~JojuI e~t te~l ~l~eO I 'slue~eJ.nbeJ uo.l~u~pompuou pu~ ~!l!q~l~ s,~JOoJd e~l eZp!lqnd oi pesn Sl~!Je~ Je~lo ~u~ pu~ ~!pe~ s~eu e~t ol pe~l~qns s~ lue~el~ls es~eleJ o!lqnd s,uo~l~z~u~JO ~u!13~JlU~ e~ jo ~d~ ~ ~V ..'saol~aS uemnH jo Tuawueda~ sexal 'UOlSlAIO slq61~ IlA!O 'JoloaJlO aql o1 XlUO pa~alaJ aq tsnm sJallaq le011llod JO UOlBIlaJ uo paseq SlUleldmOO UOlteUlmlJOSlO :gION '0g:0: '0'O 'uotBulqse~ 'a~nllno!JBV lo ~elaJoaS aq~ Jo 0~06~tZgZ sexel 'ulisnv '0~06bt xo8 'O'd uemnH jo luamuedao sexal '90L-~ O~ 'UOISlA!O slq61~ IlAIO 'JOIOeJIO :O1 RlalelPamml e11J~ plnoqs lSUleBe peleUlmUoslp uaaq aAeq ~aqt ~eqi SaAaUaq oq~ euo~uv 'lallaq leo!luod Jo 'uo!B!laJ '~llllqes!p 'aBe 'xes 'ul6lJo leUOlleU '~oloo 'eoeJ Jo esneoaq lsule6e peteulm~Jos!p eq 1ou lsnm me~BoJd eql u! aled~olued oi alq[B!le eJe oq~ eldoed 'petsll (s)e%ls eq% %e peplAoJd eq II1~ Slea~ 'me~5oJd aoI~aS poo~ ~a~mns aql jo dtqs~osuods aql saounouue (uo~tez~e~l~ ~ jo ~eN) :lucretiUs ~u!~olloJ eqt pu~ sei!s pe~oJdde lle to lSil ~ '~n~!u~ e ~e 'u!elu~ lsn~ lue~eounouue eql s~eJ0o~d Jeqlo lie ,'saol~as uemnH jo iuam~edaQ sexa~ 'UOISlAIQ slq61M UAIO '~oloeJIQ eql Ol ~lUO paJJaJaJ ~ lsnm sJallaq leOll!lod ~o uol6UaJ uo paseq sluleldmoo uoileulmlJOS!~ :g~ON '0g~0~ '0'~ 'uol~ulqseM 'eJnllnOlJBV jo ~eleJOeS eql 0~06~[ZgZ sexa~ 'uBsnv '0C06~L xog 'O'd 'saoi~aS uemnH jo iuam~edaQ sexa~ '90L-~ ~ 'UOlSlAl~ siq~lM IIAIO 'JotoeJIQ :o1 Xlalelpamml alU~ plnoqs Isule6e paleUlmlJoslP uaaq a,eq Aaql leqt saAellaq oq~ auoXuy 'lellaq leOltllod Jo 'UOl611a~ 'RllllqeSlP 'a6e 'xes 'ul61JO leUolleu 'JOlOO 'eoeJ jo esneoaq lSUle6e paleu!m!JOSlp eq lou lsnm me~6o~d eql Ul eledlol~ed o1 eJe oq~ eldOad 'patSll (s)allS eql le paplAoJd aq II!~ slea~ 'a~nllnoH6V Jo iuam~edaQ satelS peilu~ eql Aq ~plRoJd aOlJd-PeonpaM pue eaJd 6UlUlmJeie~ Jol spJepueIs aH1 6ulsn emooul pue ezls XllmeJ uo peseq eq II1~ Xilllql6lle emOOUl 'meJ~Jd aOl~aS poo~ Jammns aql jo dlqsJosuods aqt saounouue (u~ez~e~!~e~iO~eN) :lue~aiets Out~ollOj eql pue '~H!qi~!la ~pd pepnoeJ pue eaJj ~ulu~mJelep JOI spJe~e[s lueJJ~ e~ jo lsfl e 'sells ~,oJdde ~1~ jo lSfl e '~n~!u!~ e le 'u~e~uoo lsn~ eseela~ s!ql '~e~5oJd lUe~llO~ue Jeqlo Jo d~ e ~uu~u~s s. UOlleZ.UeOJo 6u~eau~ e~ :eseeleJ s~eu e qli~ me~ Xlddns pue meJ~o~d eqt ~o ~ua~unouue o!lqnd e eaem iI~ e!pa~ s~eu ~eool aU1 le~ emsua ot suoija e~e~ I1.~ uo!teztueSJo ~u!~e~u~ eqL' eseele~ oflqnd · la~ aq II!~ Jo ueaq a,eq sluamaJ~nbaJ lie leql SHQ samsse pue '.Slee~ JoJ NeleJedes e~eqO le~t s~eJ~o~d lue~llo~ug Ja~O pue sd~eO JOl seou~mssV leUO!l!ppv. 'uotleofldd~ s!qt o1 g luem~e~V peeJ seq uo~ez!~Jo 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 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 as the SFSP, Federal Regulations (7 Code of Federal Regulations [CFR], Part 225). MUTUAL AGREEMENTS The Parties mutually agree: A. If the contractor fails to provide services in accordance with the provisions of this contract, the Department may, upon written notice 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 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;, orr the part of ekher 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 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 respective accrued interest 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 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. II. CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT A. The contractor will 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 TDHS. The contractor further agree~ to perform as described in its application (including supporting documents and approved amendments to the application) for participation in the SFSP. B. The contractor accepts final administrative and financial responsibility for food service operations at each site sponsored by the contractor. This responsibility includes the performance of. the cenditiom, of. eettlemeat.~.any audit,exceptions or payment deficiency in the program and the collection and repayment ~-any .amount-paid in excess of the proper claim amount which are found after monitoring or auditing by TDHS 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 application and for prior authorization for field trips if meals served on the field trips will be claimed 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 notify TDHS within five (5) days of the termination of an approved food service site. III. SFSP RECORD KEEPING A. The contractor will keep financial and supporting documents, statistical records, and any other records pertaining to the services for which a claim is submitted. The records and documents will be kept for at least three (3) years and ninety (90) days after the termination of the contract period. If any litigation, claim, or audit involving 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 after the termination of the contract period and until all litigation, claims or audit f'mdings are resolved. The case is considered resolved when a final order is issued in litigation or a written agreement is 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 TDHS to inspect facilities 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 TDHS. Non School Spoosor~ - Page 2 IV. CIVIL RIGHTS POLICY COI~fPLIANCE A. The contractor agrees to comply with Title VI of the Civil Rights Act of 1964 (Public Law $8-352), and all requirements imposed by the regulations of the Department of Agriculture (7 CFR, Parts 15, 1Sa and 15b) Department of Justice (28 CFR, Parts 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 Disabilities 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 Adll~in~trat~v~. Code.. ~ 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 from participation 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 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 reliance on the representation and agreements made in this assurance. D. This assurance is binding on the contractor, irs successors, transferees, and assignees as long as it receives assistance or retains possession of any assistance from TDHS or USDA. The person whose signature appe~u~ o~this contract is anttmriz~m mal~ this assurance on behalf of the contractor. TDHS CLAIMS PAYMEN'T TDHS will, subject to the federal appropriation and availability 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 this contract occurring prior to (a) the beginning effective date of this contract or 0o) a later date established by TDHS based on the date of receipt of a fully executed copy of this contract. Non School Sponsors - Page 3 Vie CERTIFICATIONS A. Immigration Reform and Control Act of 1986 - The contractor agrees to comply with the requirements of the Immigration Reform and Control Act of 1986 regarding employment verification 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, Suspension, Ineligibility, or Voluntarily Exclusion For Covered Contracts - The contractor certifies, by execution of this agreement, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participating in this contract by any federitl department or agency or by the State of Texas. By making .thia. certification.the contractor agrees to the following terms: 1. The above certification is a material 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 certification, in addition to other remedies available to the federal government, the Department 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 certification is submitted if at any time the contractor learns that the certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 3. The words "covered contract,' "debarred," 'suspended,' 'ineligible," "participant," "person," "principal,' "proposal,' and "voluntarily excluded,' as used in this certification 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 submitting this certification that, should the proposed covered contract be entered into, it shall not knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the Department of Health and Human Services, United States Department of Agriculture or other federal department or agency, and/or the Texas Department of Human Services, 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, in all covered subcontracts and in solicitations for all covered subcontracts. 6. A contractor may rely upon a certification of a subcontractor that is not debarred, suspended, ineligible, or voluntarily excluded from the covered contract, unless it knows that the certification is erroneous. A contractor must, at a minimum, obtain certifications from its covered subcontractors upon each subcontract's initiation and upon each renewal. EFFECTIVE DATE AND SIGNATURF-q For the faithful performance of the terms of this contract, the parties hereto in their capacities stated, affix their signatures and bind themselves. Cit~ of Denton Name of the Contracting Organization (Please Print or Type) Lloyd Harrell Name of the authorized representative of the contracting organization (Please Print or Type) City Manager Title Please print or type, in the spaces provided above, the name and title of the authorized representative signing this agreement on behalf of the contracting organization. TEXAS DEPARTMENT OF HUMAN SERVICES Effective Dates: through By: Date: Revised February 1994 Vie CERTIFICATIONS (continued) 7. Nothing contained in all the foregoing shall be construed 'to require establishment of a system of records in 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 in the ordinary course of business dealings. 8. Except for contracts authorized under paragraph 4 of these terms, if a contractor in a covered contract knowingly enters into a covered subcontract with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other'renmdh~ available to =tl~ f.edera~ 'government,-Department of Health and Human Services, United States Department of Agriculture, . or other federal department or agency, as applicable, and/or the Texas Depart.ment 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 was-placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed 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 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 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, ameru:lment, 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 ~--influ~w.~ nn 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 subrecipients shall certify and disclose accordingly. The contractor certifies that all information 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. -.~ s~.~ SUMMER FOOD SERVICE PROGRAM FOR CHILDREN CIVIL RIGHTS QUESTIONNAIRE- C1V;,'. RIGHTS ACT OF 1964 A. 1. E~limato, by r-ac[al/ethnic group, the number of children that will participate in the program at each site. If the program COnSists date of session: or' several camp ~,~ ,~ ~.~,.,,f tho pro~ectod number of children by site and (name of alta, echeel, camp, tlc.) INDIAN NATIVE 10 5 5 Wilson ~E~ementary School Rivera ~.Aementary School 100 100 20 Owsley Neighborhood 20 15 5 TWU Clubhouse Program I0 1~0 35 uenla Park "[-0 l0 fO Phoenix Park 50 30 t0 Civic Center Park " MLK Recreation Center Village East Apartments 20 10 20 · · . · ' students, student surnames, etc. 2. Descn~e how this proiection was mede (La., based on compamtrve enrollment m sites, observat~n of Observation of neighborhoods 8. Does the organization have specific membership requirements which result in the denial of . r'-] Yes [] No program benefits to specific groups? .............................................................. If yes, describe those requirements: : C. VE~at efforts will be made by the organization to contact minority and grass roots organizations about the opportunity to participate in the program? ?osters displayed in neighborhoods, attend community meetings and public service announcement s D. What other outreach stops will be takan by the organization to ensure that minorities in the area from which it draws its attendance will have an equal Opportunity to p~-ticipate in the program? S.F.S.P. information will be printed in spanish Has any federal agency notified the organization of non-compliance with the Civil Rights act of 19647 .............. r']Yes [] Nc If yes, give detaits including dates, names, and resuEs: REHABILITATION ACT OF 1973 (Section 504) A. Does the contracting organization have any policies, practices, or architectural barriers that limit, deny, or discourage participation in the program or emptoyment by the contracting orcsanization because of disability? ........ [] Yes [] No If yes, explain: Are there any Ix~ioies or I~act~ that result in unequlJ t~etment in the delM~y of bensflt~ o~ services to participants, epplio~nts, or employees according to disability? ................................. [:::]Yes [~] No if Yes, explain: Does the contracting organization employ 15 or more people? ......................................... ~ Yes ~l. No If yeS: 1, Enter the name and title of the coordinator who will work with DHS to ensure that Section 504 requirements are met. I Name 'lille Brenda Burton Children's Programs Supervisor 2. Has the organization established grievance procedures that incorporate appropriate due p~oce_~<_ standards? ..................................................................... [] Yes [] No If yes, do these procedures provide for the prompt and equitable resolution of complaints that allege an action proh~ited by Section 504 of the Rehabilitation .Act. of 19737 ................. [] Yes [] 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 descn'be how the public was informed: There 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 ~or filing a comPlaint. D. Has the organizaton taken steps to notify employees, participants, and applicar~s that the organization does not discriminate on the basis of disability? ..................................................... [] Yes [] No If yes, do the people notified include those with impaired vision or hearing and members of unions or professional ;~ organizations holding collective b~'gaining or professionaJ agreements with the contracting organization? ........... r'~ s ~'~ No If yeS, briefly descn'be how they are notified: The visually or hearin~ impared are notified through radio and television advertisement. Also flyers, announcements, etc. are mailed Do all organization forms, publications, and recruitment materials which inform the public of program benefits and employment opp~3rtunities contain the assurance that the organizationdoes not discriminate on the basis IT7"t I"-1 of disab~ity? .................................................................................. Yes No If no, indicate steps be;rig taken to comply with this requirement: ,=. Does the organization have a procedure to ensure that the remedial or corrective action has been or will be taken if non-compliance with non discriminaiton requirements is found by OHS, USDA, o~ the contraming organization itself? .............................................................................. ~-] Yes [] No If yes. explaim: If not handled within the department in question, the City ~enerally channels all complaints through the Legal Department. Fo(m ~$06f~ctachment · SUMMER FOOO SERVICE 'PROGRAM FOR CHILDREN Paga ~. COLLECTION OF PAYMENT OP'I:IONS FOR PROGRAMS THAT CHARGE E~PARATELY FOR MEALS (Camps and Other Enrollment Programs Only) COLLECTION PROCEDURE 1) Each day, children can buy ~Jckets in the food service manager's office, but they do not receive the tickets. The food ser- vice manager sends the purchased tickets and tickets for free meal recipients to the site each day. The site supervisor distributes the tickets just before meal time. The tickets are coded for accounting purposes. COLLECTION PROCEDURE 2 Each day, children pay for their meals in an office. A list with the names of ell children who paid or ere eligible for free meals is prepared and sent to the meal service area. A staff member who know~ the children checks the names as children pau through the line or otherwise receive their meal. After the service of the meal, the list is returned to the office for accounting purposes. This method works only in e small site where the staff member knows all the children. COLLECTION PROCEDURE 3 The site ruperYisor gives each child an envelope fo?'daily, weekly, session or monthly payments. Chii~lren return the envel- o~1 with the payments enclosed, or empty if eligible for free meals. The envelopes ere colle~te~ in the office and coded tickets are issued to each child. COLLECTION PROCEDURE 4 Parents pay in advance by the month or session. Each site supervisor receive~ a llst of those children who have paid. The site supervisor marka the list as paid for children who receive free meals. Only the bookkeeper knows which children receive a free meal. The site supervisor keeps daily records of each child served and sends the records to the office for counting purposes. COLLECTION PROCEDURE 5 Meal payments ere ccIlected in the office. Payments can be made by children or parents on a daily, weekly, session or monthly basis. The secretary records payment~ and knows which children qualify for free meals. At the sites, the secretary distributes identical tickets labeled only with the children's names. Since the parents may make payments, even children who receive free meals may not know whether their meals are free or paid. COLLECTION PROCEDURE 6 Parents are billed monthly or by session for paid meals their children are served. Parents mail in all payments. All participa- ti.ng children receive a coded ticket each month, which is punched at each meal service. At the end of the month, the tic- kets are collected and a clerk calculates the amount to be billed. COLLECTION PROCEDURE 7 Other: Explain in detail (attach a sheet if more soac~ is requiredl. The contract, or must ensure :hat this me:hod prevents the overt identification of children receiving free meals. ;orm l$O$/Attac:qmen! B SUMMER FOOD SERVICE PROGRAM FOR CHILDREN :~mn,J~ '~g90 ADDITIONAL ASSURANCES FOR CAMPS AND OTHER ENROLLMENT PROGRAMS ' THAT CHARGE SEPARATELY FOR MEALS As required in Sect/on V of this application, the contracting organization assures the Texas Deportment of Human Services that: 1. The method of collecting meal payments will protect the anonymity of children who receive free meals. 2. The organization has or will e~tablish a hearing procedure for families wishing to appeal a denial of an application for free meals, which provides the following: A. That a simple, publicly announced method will be used for a family to make an oral or written request for a hearing; B. That the family will have the opportunity to be auisted or represented by an attorney or other person: C. That the family will have an opportunity to examine the do~Jmant~ and recoils supporting the decision being appealed both before and during the hearing; O. That the hearing will be reasonably prompt and convenient for the family; E. That adequate notice will be given to the family of the time and place of the hearing; F. That the family will have an o(0portunity to present oral or documentary evidence and arguments supporting its position. G.examineThat theanyfamilYadverseWill witnesses;have an opportunity to question or refute any testimony or other evidence and to confront ~nd cross- H. That the heating will be conducted and the decision made by a hearing official who did not participate in the action being appealed; I. That the decision will be based on the documentary evidence presented at the hearing and made part of the record; J. That the family and any designated representative will be notified in writing of the decision; That a written record will be prepared for each hearing, which includes the action being appealed, any documentary evidence and a summary of oral te~imony presented at the hearing, the decision and the reasons for the decision, and a copy of the notice sent to the family; and L That the writ-ten record will be maintained for a period of three yeats and 90 days following the conclusion of the hear- ing. during which it will be available for examination by the family or i~ representatives, end officials of the Texas De- partment of Human Services (TDHS}, the United States Department of Agriculture end other relevant officials as deter- mined by TDHS at any reasonable time and place. 3. If a family reques~ a hearing, the child(ran) will continue to receive free meals until a decision is rendered. Summer Food Service Program Sack Lunches Menus Eleven Day Cycle Tuesday - May 30 Peanut Butter/Jelly Sandwich 2 oz Peanut Butter, 1 T. Jelly, 2 slices Bread Carrot Sticks 1/4 cup Banana 1/2 cup Lowfat Milk 1/2 pint Wednesday - May 31 Bologna/Cheese Sandwich 1 1/2 oz Bologna, 1/2 oz Cheese 2 slices Bread Carrot Coins 1/4 cup Mixed Fruit 1/2 cup Potato Chips Lowfat Milk 1/2 pint Thursday.- June 1 Tuna Salad Sandwich 2 oz Tuna 2 slices Bread Pickle Spears 1/4 cup Orange Juice 6 oz Lowfat Milk 1/2 pint Friday - June 2 Ham/Cheese Sandwich 1 1/2 oz Ham, 1/2 oz Cheese 2 slices Bread Whole Pickle 1/4 cup Fruit Cup 1/2 cup Cookie Lowfat Milk 1/2 pint Monday - June 5 Deli Sandwich 2 oz Meat 2 slices Bread Pickle/Carrot 1/4 cup Apple 1/2 cup Lowfat Milk 1/2 pint Tuesday - June 6 Peanut Butter/Jelly Sandwich 2 oz Peanut Butter, 1 T. Jelly 2 slices Bread Carrot Sticks 1/4 cup Banana 1/2 cup Lowfat Milk 1/2 pint Wednesday - June 7 Deli Sandwich 2 oz Meat 2 slices Bread Pickle/Carrot 1/4 cup Apple 1/2 cup Lowfat Milk 1/2 pint Thursday - June 8 Tuna Salad Sandwich 2 oz Tuna 2 slices Bread Pickle Spears 1/4 cup Orange Juice 6 oz Lowfat Milk 1/2 pint Friday- June 9 Ham/Cheese Sandwich 1 1/2 oz Ham, 1/2 oz cheese 2 slices Bread Whole Pickle 1/4 cup Fruit Cup 1/2 cup Cookie Lowfat Milk 1/2 pint Monday- June 12 Bologna/Cheese Sandwich 1 1/2 oz Bologna, 1/2 oz Cheese 2 slices Bread Carrot Coins 1/4 cup Mixed Fruit 1/2 cup Potato Chips Lowfat Milk 1/2 pint Tuesday - June 13 Deli Sandwich 2 oz Meat 2 slices Bread Pickle/Carrot 1/4 cup Apple 1/2 cup Lowfat Milk 1/2 pint CITY of DENTON, TEXAS MUNICIPAL BUILDING / 215 E. McKINNEY / DENTON, TEXAS 76201 May 1,1995 Ms. Laurie Callahan, Registered Sanitarian 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 Services for a grant to provide the Summer Food Service Program to the children of Denton. This program will provide lunch for children ages 1 - 18 years of age. The food preparation will be contracted with the Denton Independent School District. We will be serving sack lunches from igloos at the sites listed below. This is a request that your department inspect the locations of food service. Time of Site/Address Dates Lunch Service Civic Center Park 5/30/95 - 8/11/95 12:00pm-1:00pm 321 E. McKirmey Phoenix Park 5/30/95 - 8/11/95 12:00pm-1:00pm Wood Street Owsley Neighborhood 5/30/95 - 8/11/95 12:00pm- 1:00pm Stella Street Denia Park 5/30/95 - 8/11/95 12:00pm-1:00pm 1001 Parvin TWU Clubhouse 5/30/95 - 8/11/95 12:00pm- 1:00pm Mary Hufford Court Village East Apts. 5/30/95 - 8/11/95 12:00pm-1:00pm 1700 Village East Rivera Elem School 5/31/95 - 6/27/95 11:45am-12:45pm 701 Newton Wilson Elem School 5/31/95 - 6/27/95 11:45am-12:45pm 1501 Emerson MLK Recreation Center 6/28/95 o 8/11/95 12:00pmo 1:00pm 1300 Wilson If you have any questions I may be reached at 566-8125. Brenda Burton Children's Programs Supervisor PUBLIC ~ ANNOUNCEMENT FOK NON-ENKOLLED SITES The Denton Parks and Recreation Department announces the sponsorship of the Summer Food Service Program. Meals will be provided at the sites listed. People who are eligible to participate in the program must not be discriminated against because of race, color, national origin, sex, age, disability, religion, or political belief. Anyone who believes that they have been discriminated against should write immediately to: Director, Civil Rights 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: Discrimination complaints based on religion or political beliefs must be referred only to the Director, Civil Rights Division, Texas Department of Human Services. Sites Address Time May 30-Aug 11 Civic Center Park 321 E. McKinney 12pm-lpm May 30-Aug 11 Denia Park 1001 Parvin 12pm-lpm June 28-Aug 11 MLK Rec Center 1300 Wilson 12pm-lpm May 30-Aug 11 Owsley Neighborhood SteHa St. 12pm-lpm May 30-Aug 11 Phoenix Park 308 S. Ruddell 12pm-lpm May 30-Aug 11 Rivera Elementary 701 Newton 1 l:45am-12:45pm May 30-Aug 11 TWU Playhouse Prog Mary Hufford Court 12pm-lpm Certification That All Required Pre-operational Site Visits Have Been Conducted At All Proposed Sites Name Of person Name Of Site Visited Date Of Visit Who Visited Site Civic Center Park April 14, 1995 Brenda Burton Phoenix Park April 14, 1995 Brenda Burton Owsley Neighborhood April 14, 1995 Brenda Burton Denia Park April 14, 1995 Brenda Burton MLK Recreation Center April 14, 1995 Brenda Burton 'I'WU Clubhouse April 14, 1995 Brenda Burton Village East Apts April 14, 1995 Brenda Burton Rivera Elementary April 14, 1995 Brenda Burton School Wilson Elementary April 14, 1995 Brenda Burton School Signature of Aut~oriz~:l Representative Date PUBLIC SERVICE ANNOUNCEMENT FOR ENROLLED SITES The Denton Parks and Recreation Department announces the sponsorship of the Summer Food Service Pro~-~. Income Eli~flity will be based on family size and income using the Standards for Dete,~finig Free and Reduced-Price Eligibility, provided by the United States Department of A~riculture. Meals will be provided at the sites listed. People who are eligible to participate in the prol~an must not be discriminated against because of race, color, national origin, sex, age, disability, religion, or political belief. Anyone who believes that they have been discriminated against should write immediately to: Director, Civil Rights Division, MC-106, Texas Department of Human Se~4ces, 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 Services. Dates Sites Address Time May 30-August 11 Village East Apts 1700 Village East 12pm-lpm May 3 l-June 27 Wilson Elementary 1501 Emerson 11:4$am-12:4$pm ***NOTICE*** The Summer Food Service Program is sponsored by the City of Denton, Parks and Recreation Depal'ment, and is offer.ed through a federal grant which requires that sponsors apply each year to retain eligibility to offer the program. It is th.erefore, our dec. laration that the SFSP will be offered this summer, from May 30th through August 11st, strictly as a PILOT PROGRAM, and that the City of Denton, PARD, is in no way directly liable or responsible for the continuance of the program in the future. o~ ~ se~,~,,$ SPECIAL NUTRITION PROGRAMS SINGLE AUDIT IDENTIFICATION DATA City of Denton Brenda Burton A~dress {Street o~ P.O. ~x. C,ly. Slate. ZIP) 321 E. McKinney Denton, Texas 76201 Ven~o~ I0 NO. Conlrac~ No. T~e~x~e No, 17560005146015 ( 8].7 ) 566-8125 C~acto~ Fiscal Ye~ End (m.m/dd/yy) Type ~ [] For Profit ~ Non-Profit ~ Governmental Check the appropriate box(es) to Indicate the ~pe(s) of program(s) in which you currently participate or for which you are applying: COMMODFrY ASSISTANCE PROGI~M$ ,: CASH REIMBURSEMENT [] A - National School Lunch [~] AD - Adult Day Care [~ I~ - Charitable Institutions [~ SE- National School Lunch/Breakfast [~ C - Area Agency on A~ing [] CC - CACFP Center [~] G - Summer Camps , [~] DH - CACFP Day Home [] H - Summer Food Service [] SF- Summer Food [] J - Jails [] SM - Special Milk Q K - Soup Kitchen UTE - TEFAP [] I - TEFA,° Commodities Give the source and amount of any federal financial assistance that your agency receives other than from those programs listed above: I SOURCE AMOUNT i see attached Name (p~ease ~ype or pr,hr) Lloyd "/-rell City Manager / ESTIMATED AMOUNTS TO BE RECEIVED FY95 Te~l.~ ~etoartt'~etlt Form 1506, Attachment C of Huma~ Ser~ce'~ Fe~lty 1991 SUMMER FOOO 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, association, cooperation, 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 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~o 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: 1. Non-compliance with applicable bid procedures and contract requirements of Federal Child Nutrition regulations. 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 limited 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 participating childrem. D. The simultaneous service of more than one meal to any ch[id. 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 use of food service management companies that are in violation of health codes. e~a~ Deeertmem July ~#0 Huma~ ,~ CERTIFICATE OF AUTHORITY This Is to certify that Lloyd Harrell City Manager is designated as the authorized representative of .Name of Contracting Organlzat~o~ C~ty of Denton A~lress (Street, C~ty, State. ZIP) 321 E. McKinney Denton, Texas 76201 The representative designated above is authorized on behalf of the contracting organization to make written agree- t~h:n:; r~let hmtehn~ ,TaenX~ st ~e%~ r~u m'~nr eStem%iuC~sSe ~eean ~r ~o ;/~r a'm, ~ ot °t ~? ~1 edp°~a r~mm:~tt,s °r re"rts ab°ut '~S~nature---Officml of Contracting AgenJ ~ Date~ IName ol Off,c~al (please type or pr,hr) ~,~e Lloyd Harrell City Manager I :OR DEPARTMENT OF HUMAN SERVICES USE ONLY: ; .~reement NO Received By I Date TX- ~ CERTIFICATE OF AUTHORITY This is to certify that Mark Shipman SFSP Coordinator S~gflat ure--Authorize¢l OffiCial is designated as the authorized representative of Name of Contracting Orgamzat~on A~-G~o (Sweet. Cdy. State. ZIP) City of Denton ] 321 E. McKinney 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 I Name of Official {please type or pr,hr) I T~ [ Lloyd Harrell I / City Manager I I FI DEPARTMENT OF HUMAN SERVICES USE ONLY: -eement No I Rece*ved By loam TX- Huma~ ~ Ju~y 1~0 CERTIFICATE OF AUTHORITY This is to certify that IName of Autho('~zed Offtc,el (ptease tyl3e or print) Tdle Brenda Burton Children's Programs Supervisor Sagnat u,e--Aut hor~ze¢l Official IS designated as the authorized representative of IN~ of COfllrec~ln~ Organization , City of Denton A~r~ (Street, C~ty, State, ZtP) 321 E. McKinney Denton, Texas 76201 The representative designated above is authorized on behalf of the contracting organization to make written agree- t~:%~ r~:hmte .~ ,TaenX~ st:~Pr:s~~u '%ar nr esl ~res~ e°~ t~ rwa~~° ° d P r ~°r igart~m,' tOOt~leg~ e~~:~tt.s Or reports a bo ut ~ %~.~../tS~gnatur.= :Official of Contract, ng ~(ncy IName °, Omc'a' (P~';~ey~e~'g')el1 I~"tlecity Manager I OR DEPARTMENT OF HUMAN SERVICES USE ONLY: ;,eement No. Received By I Date TX- ' ~ ~ SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION I TX */ ~}g [::]u Village East Apartments (817) 566-8125 ~ ~ ~ (~l. ~. S~. ZiP) 1700 Village East Denton, Texas 76201 ~~MF~(~J~y~.~J~y~.) ~ Num~rofO~ ~'~2 ~2 ~2~ ~' ~: 5/30/95 ~h: 8/11/95 e~tl~ Days: TACH A MAP W~ ~E S~E SERVICE AREA IDEN~FIED ~ ~ ~s se~ by ~is site: Denton ..................................................................................................... B. Is ~r ~e enrol~d? ................................................................................................. ~Ye~ ~No C. Site Elig~ili~ E~er ~e ~r~mage of ~Mr~ e~ib~ f~ f~ a~ r~ ~ ~s f~ ~ ~e (SFSP Ha~ ~pier II) .... 1 O0 O. If o~n sites, submit d~mentat~n suppling this ~r~nta~ f~ore (s~ ~ ~us date, ~ da~). F~ ~n ~es u~ ~ data, list ~e ~ls used ~ d~ment s~e eligib~i~ a2a~ fo~ula u~ by ~1 dist to es~h ~r~nta~ ~ fr~ & r~ ~ ~ren. E. For enrolled sites, Form 1531 will be used to document eligibility. I! the enrolled site used sc~hool data, list the school used to document the site:. F. What ~S the percentage of free or reduced-price meals for the site? ............................... 100 D~d the site participate in previous years' SFSP? (SFSP Handbook, Chapter II) .......................................... I~Yes [] No If Yes, g~ve name of contracting organization: City of Denton Mon,tonn9 Plan (SFSP Handbook, Chapter III): Enter date of monitoring review to be conducted within: A. ;,~, wee,~ bt OI3e~l~,o~ i e. P~rst Fo~x weeks bt O~er&t~on C. Ad~bona~ ReVieWS June 2 ! June 22 July 20 August 10 Meal Serwce Penod information SFSP Handbook, Chapter II): I N~MBER OF MEAL. ~ERVtCE T1ME 'TYPES OF MEALS EUGIOLE CHTL.DREH ! TO BE SE~V[D' e;~INNING Breakfast A.M. Supplement Lunch { 50 ]_2:00 p.m. 1:00 p.m. P.M. Supplement Supper Do you plan to feed children under one (1) year old? ..................................................................... DYes [] No Method of Food Prel3aration by Contracting Organization (SFSP Handbook, Chapter II) 5e~f-P,~at,o~ I ve,xl~ Using School Using Food ~ewlce Management Using Private Non-Pror~ i ~.-]C~feterta.~tyte I"'1 Chlldref~ Ire Seated a?-~ Children ~ Up Ideal Service I I and a~ Given Idesls IAI Ind Pick Up Meals [] Othec, 0. t. Jst site personne! who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II): l'~f~.~ O~ I'0srTION I~0. II I~0~'10. ~-ECIFIC FO00 SERVICE PROGRAM DUTIES Site Supervisor 1 Supervise and a.~.~;r dt.~tr;h,,r~n ot~ m~=lc~_ m~,,'~f'rwr' and mainca~m m~ml temperature. ~ c1o~._,_,~ and Site Helper/Server 1 Assist site supervisor 1. indicate what provisions will be made for meal sen~ce during periods of inclement weather. (SFSP Handbook, Chapter II) [~] ~k~ldeal f-...n Meal Service I IWill Be Csncelled [] Other: 2. If the site feeds p~imarily hometess children, what methods are used to ensure that money, food stamps, or in-kJfld services are not required for meals? N/A 3. Are meals delivered to the site? ........................................................................................... [] Yes [] No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOl"TOM. ~. Indic. ale the means of commurdcalion with the vendor which roll be used to adjust meal deliveries. (SFSP Handbook, Chap. II) r..~ Slte Personnel Will Contact Administrative r'-J Site Personnel Will Communicate Staff, Who Will Contact Vendor L...] Directly With Vendor 5 Will delivery be within one hour of the food service period? (SFSP Handbook, Chapter II) ...................................... l'"~Yes DNo If no, describe arrangements within standards prescribed by local health authorities for delivery and holding o~ meals until time of service. if there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III) i~ Stored in Refrigerator r'-'lThr°vm Away r--i Returned to Vendor ~ - and Served the Nexl Day IIst the Site /1~ for Disposal I IOther. // 2ERTIFY th/at,he information on this form is true.,a~,.~/~orrect to the best of my knowledge. I certify that this site has been visited ~nd the,' c the ca~'abili/Vy and fadli*Jes.for ~e meal ser~ic~'/~)r~,~ned for the number of children anticipated. I know that deliberate misrepresentat}~ o' Lloyd Ha/tell I City Manager · S~nalaJfO-OHS Re~re~ntat~'e Date SITE INFORMATION TX R [~u v~F~dS~SM ] (817) 566-8125 Phoenix Park Wood Street Denton, Texas 76201 =~: 5/30/95 ~h: 8/11/95 ~ACH A MAP W~ ~E SITE SERVICE AREA IDEatED ~ ResMenhl ~p ~ ~ M~ P~ ~mnt C~mn B.(~ ~r ~) ~ '.. ~ ~s ~ byes s~: Denton C. Site Eligibili~ E~er ~e ~rmntage ~ ~i~ e~gi~ l~ fr~ ~ r~ D. If o~n sites, submit ~mentat~ suppling ~ ~r~n~ f~ure (s~ M ~ date, ~ da~). F~ ~n s~es usi~ ~1 data, list ~e ~s used ~ d~ment s~e eligibili~ aUa~ fo~u~ u~ ~ ~ disL to es~i~ ~nta~ ~ fr~ & ~ ~ ~ren. E. For enrolled sites, Fo~ 1~1 ~11 ~ used ~ ~ment If the enrolled site used s~l da~. list ~ s~ u~ to d~nt ~e site: F. What ~S the Dercen~ge of free or redu~d-pd~ meals for ~e site? ................................................. D~d ~e site peri.pate in previous yearn' SFSP? (SFSP Hand.k, ~apter I~ .......................................... ~Yes ~No !f Yes. give name of ~ntra~ing organization: C~:y o~ Monilonng Plan (SFSP Handbook, Chap,er III): Enter date of monitoring revi~ to be ~ndu~ ~hin: Meal Se~ Pe~od Information (SFSP Handb~k. Chapter II): t ~MBER ~ ME~ ~R~ ~ME i ~PES OF ME~S : EUGIB~ C~EN ~ TO BE SERVED' BE~NG Breakfast A.M. Supplement ~n~ ~ 90 t2:00 p.m. [:00 p.m. P.M. Sup~ement Super 'T~ ~ ~ ~ ~ ~ ~n ~ ~ ~ ~M ~ ~ll. (SFSP ~ ~ II) ~ you ~an to f~d ~ildren under one (1) year old? .................................................................... ~Yes Me~ of F~d Preparation by Con~a~inq O~aniza~on (SFSP Handbook, Chapter ~.~t~ ~ v~ USI~ ~1 UsI~ F~ D Cl~ete~,e-ltyle r--'s Cldldrln Ire seated ~ CMIdmn Uae ~ Meal set/ice L..J ~nd stt Given 14eals ~1 and Pick Up Meals [] Other:. ' 0. List site personnel w~o will be involved to any extent in the meal serv~e. (SFSP Handbook. Chapte~ II): 1Trt. E OF PO$ITION HO. 14 I~o$moN ~Ec#qc FOOO SERVtCE Iq~OGRAM O4J'nEs Site Supervisor 1 Supervise and ~;.~{;r di;tr~h,,r~ n~ m~l,~_ mnn~rnr and maimt~{n m~m] temperature. .~{r. .1oo.-.,. anH Site Helper/Server I Assist site supervisor · 1. Im:lic~.le what provisions will be made for meal sem~ce during periods o! in~ement weather. (SFSP Handbook. Chapter II) E~i~Meal r'-~Meal sen/lee I IWill Be Cancelled [] Other: · ~. If the site feeds primarily homeless children, what methods are used to ansure thai money, food stamps, ~ in-kind sero, ices m'e nol requi~ed Io,' mea~s? N/A '3. A~e meals delivered to the site? ........................................................................................... I"~Yes I'~No IF YES, COMPLETE ITEMS 14, 1S, & 16. IF NO, FORM IS ~OMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 4. Indicate the means of communication with the vendor which re'Il be used to adjust meal deliveries. (SFSP Handbook, Chap. II) 1~ Site Personnel Will Contact Administrative I-'1 Site Retrofit41 Will Communicate Staff, Who will Contact Vendor I IDirectly With Vend~ ~ 5. Will delivery be within one hour of the food se~,vice period? (SFSP Handbook, Chapter II) ...................................... ['-~¥es [-'~ No If no, describe arrangements within standards prescribed by local health authodlie$ fo~ delivery a~d holding of meals u~til time of sewice. 5 If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III) ~.j Stored In Refrigerator r.-~ Thrown Away r'"-~ Returned to Vendor r'--, ' and Sewed the Next Day L_Jlt the Site ~,...J f~ DiSposal L,_lOther: ~ERTIF'Y ~_~..the inform~on o~, this form is ~ a~d correct to the best of my knowledge. I cetlity that this site has bee~ v~sited and t~a: .' ~$ me c.~b~'ity and fatalities f~ the meal se~anned for the number of children antidpated. I know that deliberate misrepresenta~o~ '.~holdi~f info.nat)on ~a¥/f~ in p$os~3'ti, gfi under applicable state and federal statutes. City of Denton L Harrell City Manager I ' ' ['--I Approved ['--IOenled, re~sofl: S~atu~e--DHS Re~'e~n~ve Dale ~ ~ SUMMER FOOD SERVICE PROGRAM FOR CHILDREH ~ to. ~s ~ ~ S~E INFORMATION I ~ */ ~R ~U ~K Recreation Center 5 ~ ~ ~t ~.S~,Z~ 1300 ~ilson Denton, Texas 76205 ~: 6/28/95 ~h: 8/11/95 emt~ Days: TACH A MAP W~ ~E S~E SERVICE AREA IDEatED ~ ~ ~s ~ ~ ~s sRe: Denton . .................................................................................................... UY. C. S~e ~ibili~ Ent~ ~e ~r~n~ge ~ ~r~ e~gi~ f~ ~ ~ r~ ~ ~s ~ ~ ~e (SFSP HaM~ ~er ii) .... 31% O.If o~n sites, submit ~mentat~n suppling th~ ~n~ f~ure (s~ ~ ~uS date, ~ da~). F~ o~n ~es usi~ ~ data, list ~ ~s used ~ d~nt sRe eligibil~ a~ fo~ula u~ by ~ disL to es~blish ~rmntage ~ fr~ & r~ ~ ~ren. 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: E What is the percentage O! free or reduced-price meals for the site? ............................. .................... 100 % Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter II) .......................................... [~"]Yes r"~ No if Yes, g~ve name of contracting organization: City of Denton Monitoring Plan (SFSP Handbook, Chapter II1): Enter date of monitoring review to be conducted within: Meal Service Period Information (SFSP Handl3ook, Chapter II): ~ NfJMSER OF MEAL. SERVICE TIME TYPES OF MEALS s E~GIBLE CHIt,.DREN I TO BE SERVED' IEGINNING EHOING Breakfast A.M. Supplement Lunch I 90 12:00 p.m. l:O0 p.m. P.M. Supplement Supper Do you plan to feed children under one (1) year old? ..................................................................... ~']Yes [] No Method of Food Preparation by Contracting On;anization (SFSP Handbook, Chapter Se~-I~.~r.~ Ive'''~e~ Usir~j Scht~l -- Usl~J Food Service Management Using Prt,vtle,Non;-,Prof 9. ledicata the system ~o be used fox the sewing c~ meals and the SUl~ of chi~ du~g mHi ~ ~. ~ Ha~ ~ ~ o Caflteft~lt,/le ~ Childlln are Seated ~ Children Line Up Meal Sewlct I lied 111 Olvlfl MeaLs I~1 ind Pick Up MSall I I Othec. ~ 0. List site personnel who wilt be involved to any extent in the meal service. ($PSP Handbook, Chapte~ TTR.E 0~' POS~30N NO. IN I~O~'lON Site Supervisor 1 Supervise and ~.~.~'l~r and maintain m~m] temperature. Site Helper/Server 1 Assist site supervisor · 1. h~icalte what Itm3~sions will be made for meal service during periods o! ir~cJemant weather. (SFSP Handbook, Chaplin' II) I IWIll Be Cancelled [] Other: · 2. If the site feeds ~marily homeless children, what methods are used to e~ure ~ money, feed stamps, (x in-kin4 services are not rKuired fo~ meals? N/A '3. Am meals delivered to the site? ................................................................................... I~"lYe$ [--]No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. · 4. ledicate the means of communication w~ the vendor which will be used to ao]ust meal deliveries. (SFSP Handl~ Chap. II) i,~Slte Personnel Will Contact Administrative ~ Site Personnel Will Communicate Staff, Who Will Contact Vendor I I Directly With Vendor · 5. Will delivery be within one hour of the food se~,ico period? ($FSP Handbook, Chapter II) ...................................... [--~lYes [] No If no. describe arrangements within standards prescribed by local health authedlies fo~ delivery and holding o~ meals u~liI lime of se~ice. · 5. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter II1) [~ Stored In Refrlgecato~ ~t'rhmwn Away I..-1Retumed to Vendo~ and Seined the Next Day I Iai the Site I Ifor Disposal DOthec 3ERTIFY th, et"~he information o,~ this lom~ island correct to the best of my knowledge. I cerli~y that this site has been visited and t~a: · as the ca, o/~il~y and faciliti/es ~r the meal~e!~[).e~ planned for the number of children anticipated. ! kx~w that deliberate misrepresentabo~ c- ~ '.,~holdi~ o~rnfo~at[o~ ~ay/e~u~t in ~'~'e~on, u~_er applicable state end federal statutes. Lloyd/arrell / USE O~LY S~I~e--OHS ReP~esentatwe Date ' TWU Clubhouse Program 5[~-8~5 Mary Hufford Court Denton, Texas 76201 mm: 5 / 30 / 95 throb: 8 / 11 / 95 ffrafing Days: TACH A MAP W~ ~E SI~ SERVICE AREA IDEatED ~ ~ ~s se~ ~ ~is s~: Den con ..................................................................................................... 8. I~ ~r ~ ~nmll~d~ ................................................................................................. ~ ~o O. ~ o~n ~it**, ~u~mit d~m~ntation ~u~in~ ~i~ ~n~ fi~ur~ {~ ~ ~u~ dat~, ~ d~ta}. For ~n E. For enrolled sites, Form 1531 will be used to document eligibility. If the enrolled site used school data, list the school used to document lhe site: F. What is the percentage of free Or reduced-price meals for the site? ............................. ..................... 100 % Did the s~te parlicipate in prewous years' SFSP? (SFSP Handbook, Chapter II) .......................................... [~Ye$ F~No If Yes, g,ve name of contracting organization: City of Denton Monitonng Plan {SFSP Handbook. Chapter Ill): Enter date of monitoring review to be conducted within: June 2 i June 22 August 10 ~leal Service Penod Information 'SFSP Handbook, Chapter II): : NUMB£1q OF ME~U. SER'ACE TiME TYPES OF MEALS EUGIBLE CH1LDREfl TO BE SERVE[)' aEGINN~NG ENDING Breakfast A.M, Supplement I . Lunch i 55 12:00 p.m. 1:00 p.m. P.M. Supplement Supper ' Ti'es ~e,tw~la¢~ ss ¢~3t~et~l b.f OHS w'ne~ Do you plan to feed children under one (1) year old? ..................................................................... r-]Yes [] No Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) ; S~,.~ r'~_ ~ S_l~t~_ ~i"~' C_?~ n ~_~ I_~ ? h~e~?. ~' .... r':~'_ Food ~, ut h o rttY ~F~I Ce~,' :a'w 0nc!udes Ill Year Contracts, ~i'~ Or,:la.lz3 ton Shat Is Se!f..,...~ . ~. thdic~le the Wstem ~o be used f<x Ihe ~,erving d meals and the supef~lion ol chtldr~ ~}u~ng meal servk=e period. (SFSP Handl~3ok, Ch&Plm' II) [-..~ Ca~tede-~lyle ~ Chtldme am $flt~l ~ CMIdmn Une U~ I~al Serdc$ ~ ~ ~ G~n ~s ~ aM P~k Up Me~s ~ ~ P. Ust ~te ~nnel ~ ~ ~ ~d to aw e~ent in ~e ~al se~. (SFSP Ha~, ~t~ I~: Site Supervisor 1 Supervise ~ m~sr d]~tr{h,,r{n, nf m..l~_ m..{~.~ 1. Ino'ic~e what provisions will be made for meal seMce during pehods ol inclement weather. (SFSP Handh.~ Chapter II) I IWill Be Cancelled [] Other: 2. If Ihe site feeds iximarily homeless children, w~t methods are used to ensure that money, food stamps, or in4dnd senses a'e nol required for meaJs? N/A 3. Am meals delivered to the site? ........................................................................................... ~']Yea IF YES, COMPLETE ITEMS 14, IS, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOT'FOM. ~. Indicate Ihe means of c~mmunication with Ihe vendor which will be used to adjust meal deliveries. (SFSP Handbook. Chap. II) i.~ Site Personnel Will Contact Administrative ~ Site Personnel Will C~mmunlclte Staff, Who Will Contact Vendor I I Directly With Vendor 5. V~ll delivery be within one hour of the food service period? (SFSP Handbook, Chaptor II) ...................................... r~Yes [] No If no, des~he arrangements within standards presc~bed by local health authorities for delivery and holding of meals until time of service. If there is an excess of meals delivered, meals will be (SFSP Handbook. Chapter III) [~j Stored In Refrigerator r--'lThr°~m Away r'--I Returned to Vendor r""l ' and SerYed the Ne~t Day I IlttheSite . I_..I for Oispos~l i IOther'. ]ERTIFY that]J'~e information on t~is form is t~ue,~correct to the best of my knowledge. I ce~lffy that this site has been visited and fha: .. the capab~'ty'and facilitie% lot,the meal serv~lfj~lanned for the number of children anticipated. I know that deliberate misrepresentation c' :.~3¢~ing p t'~ormatio~ ~ re~fult~in prosJl~l~{f~JKun,~ler applicable state and lederal statutes. ,..~ ~ 0~. ~ ~m~ ~ ~n~ Ll~d Harrell Ir' City Manager ~ S~g~aIu~e-DHS Relxes~n~tr~e Date SITE INFORMATION It I-'lu ~F~dSIn~SM ] (817) 566-8125 ~sley Neighborhood Stella St. Denton, Texas 76201 ~ACH A MAP W~ THE SITE SERVICE AREA IDE~FiED ReMen~l ~p S~ i~MT~Site: ~ ~(~w~tmals) B.(~to~) ~ D.(~w~r~) ~ ~ ~s se~ by ~s s~e: 5. Is ~r ~e en~l~? ................................................................................................. ~Yes C. S~e El~i~li~ E~ ~e ~n~ d ~i~r~ eligible f~ f~ a~ ~ ~ ~ ~ ~ s~ (SFSP Ha~ ~pt~ Il) 1 9 % D. If o~n sites, su~it ~ntat~ supping th~ ~r~n~ f~e (s~ ~ ~us date, ~ data). For ~n ~es usi~ ~ data, list ~ s~s used ~ d~nt sAe el~ibili~ a~a~ fo~u~ u~ by ~ disL to es~blish ~nta~ M fr~ & r~ ~ ~ren. ~/A E. For enrolled sites, Fo~ 1~1 ~11 ~ us~ ~ ~nt eligi~li~. If the enrolled site us~ ~ da~, list ~ 100 % F, What ~s the per~n~ge of free or redu~d-pd~ ~als for the ~e? ............................... Did ~e site paAidpate in previous yearn' SFSP? (SFSP Hand.k, Chapter I~ .......................................... ~Yes ~No If Yes. g.ve name of ~n~a~ng organization: CiL~ o[ Denton Monitonng Plan (SFSP Handbook, Chapter Ill): Enter date o~ ~nitoring revi~ to be ~ndu~ed within: June 2 I= June 22 July 20 August i0 Meal,..... _.Sem~ .... Penod. ....... lnfo~ation .SFSP Hand.k, Cha ~te~ II): ~ ~MBER ~PES ~ ME~ : EUGiB~ C~EN TO BE SERVE~ BEGIN~NG E~K 8reakfas~ A.M. Supple~en[ ~ 1:~0 p.=. ~n~ I ~0 ~2:0~ ~.~. P.M. Supplement ~ yOU ~ tO I~d ~ildren under one (1) year old? ..................................................................... ~Yes ~ No Me~ of F~d Preparation ~ Con~a~ng O~aniza~on (SFSP Handbook. Cha~ter II) ..~ v~. UsI~ ~ On Site ~ Central Kitchen~ F~ Authort~ ~ Compa.y Oncludes All Year Contacts) ~ O~anlMtlon ~t ~ Se~-Pre~ I indiclte the system Io be used for the 14~/mg d meals and the sup~ d d~ldrln during ~ ~ ~. ~FSP H~ ~ ~ Meal Service I I and am Given ~ ~ and Pick Up Meals List site ~rsonnel who wifl be bwolved to ~ny extent in Ihe meal service. (SFSP Handbook. Chapter II): TITLE Ofr POS~'IGN NO, Ii Posmofl ~PECIFIC FO00 SERVICE PI~OGRAM D~Tii Site Supervisor 1 Supervise and a.~.~r dtm~r~h,,r~nn Site Helper/Server 1 Assist site supervisor ~. Indtcate what i~ions will be made ~o~ meal serv~e dudng pe~)ds of inclement weather. (SFSP Handbook Chapter II) U will Be Cancelled [] Other: 2. ff the ~te feeds p~mad~/home,ss ch~dren, w~at men,ds are used to erasure that money, food stamp~, or ~-~nd serv~es a~e ne4 requ~ed for me~s? ~/A 3. Are meals delivered to the s~e? ........................................................................................... ~Ye~ ONo IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 4. Indicate the means of communication with Ihe vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. II) ~] Site Personnel Will Contact Administrative r-'q Site Personnel Will Communicate Staff, Who Will Contact Vendor I 1Oir~tly with Vendor 5 Will delivery be within one hour o! the food service period? (SFSP Handbook, Chapter II) ...................................... GYe$ [] No If no, describe arrangements within standards prescribed by local health authorities Io~ delivery and holding of meals until time of service. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III) [ X.~.-j Stom~l in Refrigerator f....1Thmwn Away r,.-.I Returned to Vendor and Sewed the Next Day I lit the Site I Ifor Disposal [~ orbed. 3ERTIFY that the~infom'mtion on this form is true and~eo~ect to the best of my knowledge. I certify that this site has be~t visited and t~a: ~: the capabili.~nd facilities l,or I~ meal serv~'/pl~ned for the number of children anticipated. I know that deliberate misrepresentabon o- :,~holding ~,'~ormalio~, may/e~'a:flt in pros~~applicabte state and federal statutes. .~m~.O~p~o~p~'~ Llo/Harrell Irm~ City Manager S~a~=DHS ReP~'esen~atrve Date Hume. ~ SUMMER FOOD SERVICE PROGP %M FOR CHILDREN I FOR OHS US'= ONLY, srrE Du ~ ~ F~ ~ ~ Denia Park ~ (817) 566-8125 ~NS ~ ~ (Suni. ~. S~te. ZiP) ~00[ ~a~vtn De~Co~, Texas 7620~ c~: ~ / 30 / 95 ~r~gh: ~ / [ [ / 95 emtln9 Days: ~ACH A MAP W~ ~E SITE SERVICE AREA tDE~FiED Res~en~l ~mp . I~teT~ ~ Site: ~ ~(~w~tof~r~als) ~ C.(~tol~r~ais) ~ E.(~tof~rmeais) ~~ ~p S~ ~ P~ ~ C~ ~. ~ ~ ~s se~ by ~is sita: De~on ~. A Is,y~r~e~n: ..................................................................................................... ~Yes ~Ho B. Is ~r s~e enrolled?.. C. Site Eligi~li~ Enter ~e ~mn=~ of D. If o~n sites, submit d~mentat~n suppling this ~r~n~ f~ure (s~ ~ ~us date, ~1 data), For o~n ares usi~ ~ data, list ~e s~s used ~ d~ment ~/~ E. For enrolled sites, Form 1531 will be used to document eligibifity. If the enrolled site used school data, list the school used to document the site: F. What ,s the percentage of free or reduced-price meals for the site? ...................................... 10070 ,~ Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter II) .......................................... []Yea i'"~No City of Denton If Yes, give name of contracting organization: ~ Monitoring Plan (SFSP Handbook, Chapter III): Enter date of monitoring review to be conducted within: A. F~tlt W~k O~ (:::)~ihO~ e. F~rst Four Weeks o~ O~-r~,~ C. Ad(:titio~al July 20 June 22 10 June 2 August ~ Meal Service Pedod Information (SFSP Handbook, Chapter II): NUMBER OF MEA~. S~RVICE T~PES OF MEALS EUGIBLE CHILJ:)REN TO BE SERVED' BEGINNING ENDING ~, Breakfast A.M. Supplement Lunch 30 12:00 p.m. 1:00 p.m. P.M. Supplement Supper 7. Do you plan to feed children under one (1) year old? ..................................................................... I-:lYes r"~No 8. Method of Food Preparation by Con~acting Organization (SFSP Handbook. Chapter II) [] On Site [] Central Kitchen , Authority [] Company (Includes All Year Contracts) II OrganlzaUon that Is Self-Prep 9. indicate the system to be used for Ihe se~ng si meals and the supervision ~ children during meal service period. (SFSP Handbook, Chapter II) D Cafetefla-style r--~ Children are Seated ~ Children Line Up Meal Service I i and sm Given Meals I~1 end Pick Up Meals [] Othec ! 0. llst site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II): TiTt. E OF POSII~ON NO. IN POSmON SPECIFIC FOSS SERV1CE PROGRAM DUTIES Site Supervisor ! Supervise and ~.m~r d~r~h:,r~nn nF m~l~_ ,.~n~. ~td mm~n~m~n mpml temperaturm, m~ ~loo~-,,p~ ~ ? 1. Indicate what Ixovisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Chapter II) [x~lndo~ Meal r--n Meal Service Service I IWlll Be Cancelled [] Other: 12. If the site feeds lximan*ly homeless children, what methods are used to ensure that money, food stamps, or in-kind senrtces are not required lot meals? ~/A 13. Are meais delivered to the site? ........................................................................................... r'~Ye$ DNo IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS ~OMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the ver',dor which wa be used to adjust meal deliveries. (SFSP Handbook, Chap. II) ~] Site Personnel Will Contact Administrative ~Site Personnel Will Communicate Staff, Who Will Contact Vendor I I Directly With Vendor ~ 5. Will delivery be within one hour of the food service period? (SFSP Handbook, Chaplet If) ...................................... [~Yea [] No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of sen, ice. · 5. if there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III) ~-~ Stored In Refrigerator r--tThrown Away r--iRetumed to Vendor and Served the Next Day list the Site I Ifor Disposal Dothec CERTIFY the, t/~he information on this ton~ is t~and correct to the best of my knowledge. I certify that this site has been visited and .that it, ~as the cap~3t~il, i(y and fadliti,es f~r the meal ~ planned for the number of children anticipated. I know that deliberate misrepresents'Son o. ,,,.ithheldi~inlormatiqn n;(ay,,fes~,~t in ~on under applicable state and tederal statutes. /~loyd Harrell I City Manager / I = '1 re-o.: , S~gnatu~e-DHS Represeniatwe Date ~x~ DMwtnlnt J FO. DHS USE ONLY ~u,~,~ Sen,k~ SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION TX ' I-'11~[]u ~~ ~(8~7) 566-8~25 Rivera Elementary School 701 Newton Dent°n' Texas 762011 ~ ~J~ ~' .~ ~ ~.~ ~ F~ ~ (~,~.~-) .um~ o~ O~ ~ M~1 ~ 19 From: 5/31/95 Ih~gh: 6/27/95 em~D=ys: ~ACH A MAP W~ THE SI~ SERVICE AREA IDE~FIED ~ Resldea~l ~mp S~ ~w~ P~ M~mnt ChIM~en ~r Sae I. IndiMtaTy~ of Site: ~ 3. ~ Is,~r s~ ~fl: .......................................................................... B. Is ~r ~te enrolled? ................................................................................................. C. Site Eligi~li~ ENer ~e ~r~n~ge of ~K e~ f~ Ir~ ~ ~ ~ ~s f~ ~e ~e (SFSP Ha~ C~ter II) ..... 2 2 % D. rf o~n sites, submit d~umentat~n sup~ ~b ~r~n~ f~u~ (s~ ~ ~us date, s~l da~). F~ o~fl sKes usi~ ~ data, list ~ ~s used ~ d~ment sKe el~ib~ 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: 100 % F. What is the percentage of free or reduced-price meals for the site? .................................. 4. Did the site participate in previous years' SFSP? (SFSP Handbook. Chapter II) .......................................... r'-'~yee r~No if Yes, give name of contracting organization: 5. Monitoring Plan (SFSP Handbook, Chapter [1t): Enter date of monitoring review to be conducted within: A_ June 1 June 21 6 Mea~ berwce r'e.uu Information {SFSP Handbook, Chapter II): HUMBER OF MEAL SERVICE TiME TYPES OF MEALS EUGIBLE CHILDREH TO BE SERVED' BEGINNING EHDIHG Breakfast A.M. Supplement tunch 220 11:45 a.m. 12:45 P.m- P.M. Supplement Supper 7. Do you plan to feed children under one (1) year old? ..................................................................... r-'lYes [] No 8. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) ~ On Site [] Cent:.; Kitchen Food Amhod~ [] Company pncludes All Year Contra~s) [] O~anb. aflon fiat b Serf-Prep r-l]nn IS0?/PiOt ~' 9. Indicate the system lo be used !o~ the se~ng of meals and the supervision of chtkken during meal servica period. (SFSP Handbook. Chapter II) DCafeteHa-styls I--t Children Ire Seated r--t Children Une Up Meal Service I I and Ire Given Meals KI and Pick Up Meals [] Othec 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook. Chapter II): 'n'rLE C~C POSmON NO. iN POSmON SPEC'FIC FOOD SESWCE PROGFdAM DUTIES Sit~ Supervisor 1 Supervise and assist distribution of meals, monitor and maintain meal temperature, site clean-up, and other duties as assigned Site Helper/Server 2 Assist site supervisor 11. Inlf~ate what prov~ions will be mede for meal serMca during periods of inclement weather. (SFSP Handbook. Chapter II) i.,~l~Meal r--,tMeal Sewlce I IWIII Be Cancelled DOther: 12. If the site feeds p~merily homeless c~ildran, what me~xIs are used to ensure that mo~y. food stamps, o~ in-kind se~ces are not requ~ed fo~ me=Is? N/A 13. M meals delivered to the site? ........................................................................................... I~Yes [] No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of communication with the vendor which will be used to adjust meal dal~. (SFSP Handbook, Chap. II) i~%-iSite Personnel Will Contact Administrative i~Site Personnel ,/All Communicate Staff, Who Will Conblct Vendor I 1Directly With Vendor 15. W~II delivery be within one hour of the food service period? (SFSP Handbcok. C'hapter II) ...................................... I""~ Yea [] No If no, describe ar~a~ements within standards pmsc~bed by local health authorities tot delivery and holding of meals until time of service. 16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III) i~ StMsd In Refflgeretor ~ Thresh Away ~ Returned to Vend~ and Served the Next Day U ~t the Site g.J for Disposal D ~ I CERTIFY tha~he information~on this form ist~ and correct to the best of my knowledge. I ce~lify that this site has been visited and that it has the cap~ity and facilities/for the meal~e//~ca planned for the number of children anticipated. I know that deliberate misrepresentation or with~liRg~ information,//n~ re, in pr~,e~fion [ruder applicable state and federal statutes. ¢:/ I ( City of Denton L~yd Harrell I City Manager S~a~'e.-OHS Representative Dale SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORM~ TION Wilson Elementary School 25 1501 Emerson Denton, Texas 76201 mm: 5/31/95 Uwo~gh: 6/27/95 ! 19 TACH A MAP WITH THE SITE SERVICE AREA IDEN¥i~ii=D r"'l RealdentialCamp ~ Site sen'lng Pdmarlly Migrant Children r&"l Other Site Indicate Type o~ Site: I IA.(s~rvlngoMlalourmeais) I IC.(sewingMtetolourme~Js) l~lF..(sewingeMIolourmeMt) e.(~erYingof~tof4wrm~) [] - .S~,YingPd,ndyHo~Chl~ u.(~mg one to Ioof meals) Ust ~ counties se~ed by, this site: Den ton 6. la your site ¢' Site E~ibititY: Enter me ~centage ~ childre~ erroi~ f°¢ free am:V°~ redKecf I:~ce meals ~ h~te site (SFSP Hat,book, Chap~ il) ..... 22 % D. If open sites, submit documantation supJx)rting this percentage figure (such as census date, SCJ'H:)OI data). FQ~ open sites using school data, list the SChOOls used to doc~mant site eligibility; attach formula used by school dist. to astab~ish percentage c~ free & reduced pf~ce children. E. For enrolled sites, Form 1531 will be uteri Io document eligibility. If the enrolled site used school data, list the school used to document the site:. --, What ~s the percentage of free or reduced-price meals for the site?.. ................................................. 100 % )id the site participate in previous years' SFSP? (SFSP Handbook, Chapter II} .......................................... F"~Yes l-~No Yes, give name of contracting organization: )~onitonng Plan (SFSP Handbook, Chapter III): Enter date of monitoring review to be conducted within: June 1 I June 21 - ~eal Service Penod Information (SFSP Handbook Chapter II): TYPES OF MEALS ~ EUGIBI. E CHILDREN ~ MEAt. SERI/tCE TIME TO~VED' BEGINNING ~reakfast I ~, M, Supplemen( ,,rich j 20 11:45 a.m. , 12:45 p.m. ~.M. Supplement ~upper t~. ~ il (~r4.C,~ m., I~ De'tS when ~,""a U'4 ~,~--,,~ved mea~ $ervtc~ level (SFSP H~,--~- --<-*~ C~..u.- you plan to feed crlildren under one (1) year old? ..................................................................... l--],es l .o ;,'hod of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) '~ On Site [] Central Kitchen I vG Using Sc,~,o~; ~.~ Using Fmxl Service Management ~ Using Pdvale Non-Profit Food Authority ~ Company (Includes All Year Conlracts) U Organl/,JGon that Is Self-Prep I--"l C~feted~"~lYle i--'l Chtld~n ~r~ $emd ~ CN~n U~ Meal ~ ~ ~ m O~n ~s ~ I~ P~k Up Me~s site ~r~nel ~o ~fl ~ ~d to ~y e~ent in ~e ~al se~. (SPSP Ha~, ~M IQ: Site Supervisor I Supervise and mmK{~r and mainCa~n m~ml temperature. Indicale what provisions w~ll be mede for meal se~ce during periods of Inclement weather. (SFSP Handbook. Chapter II) [~S~eMeal r--'~"ell Servk:e I Iwill Be Cancelled [] Other: site feeds ~ma,-ily ~omeless c~k:lren, w~at methods &'e used to e~sure that mo~ey, fccd stam~, ~ ~ se~kes ~e nol requ~ed f~' me~s? N/A A,.'e me~s delivet'ed to ~ site? ........................................................................................... ['~Yea GNo IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS ~OMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. Indicate the means of communication w~th the vendor which will be used to adjust mea~ deliveries. (SFSP Hano'-uook. C~o. II) [:~ Site Personnel Will Contect Admlnlstr-tlve r"""lSite Personnel Will ~)mmuntclte Stiff, Who Will Contact Vendor I IDIrectly With Vem~ Will delivery be wi~in one hour of the food se~'vk~e period? (SFSP Handbook. Chapter II) ...................................... l"~Yes [] No If no. describe anangements within standarOs pres~bed by local health authorities fo~ delivery and holding o~ meals until time of sef'~e. ~ if there is an excess of meals delivered, meals will be (SFSP Handbook. Chapter III) [:~ Stored In Refrigerator r-qThrown Away ~ Returned to Vendo~ end Se~ed the Ne~ Day [ lit the Site I I for Disposal [] Other:. _~T~ th~!..the ~?~.....~o,?n..~s ~o,~. is ~. ~,~. d co,ec~ to the ~st o~ ~ ~o~.dge. ~ce~ that th~s site ~s ~ ~ e eapa~..g~ an~ mo|mes~ ~or ~e mere se~j~ planned for ~he numper of ~ildren antidpat~d. I Imo~ that deliberate ~-~g/~l'nfo~natiofl/may~re~it in prgs~./~n under applicable state .~.,~e~ ~sta.~:~.G~._' .', yd Harrell I City ~nager ~DHS Re~e~n~t~ Date ~ Hm~n ~ SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FO~ m4s use O~LYi SITE INFORMATION ~F~~ ~(817) 566-8125 Civic Center Park 321 E. McKinney Denton, Texas 76201 Fr~: 5/~O/95 ,h=gh: 8/11/95 INum~r°fO'e~U~Days: ~ ~2 ~ 21 ~'9 ~t. ~ACH A MAP WI~ ~E SITE SERVICE AREA IDE~FIED ResMen~l ~mp S~ ~w~ PH~rily MIg~l Chi~n ~ ~r SHe 1. Indi~teT~ of Site: ~ ~(sewl~to~rm~) ~ C.(~l~r~) ~ E.(.wl~one~rmeds) ~n~s~ ~p ~ h~ p~ ~ Ch~ ~B.(..~hr~) ~D.(---l~r~) 2. ~ ~s served by ~is s~e: B. Is ~r ~e enrol~d? ................................................................................................. ~Y~ ~No C. S~ ~li~: E~r ~e ~r~nt~ d ~ren e~ I~ f~ ~ red~ ~ ~s ~ ~ ~e (SFSP H~ ~ II) .... 2 2 % D. If ~n s~es, submit ~umentation supping t~ ~r~n~ge tigure (s~ ~ ~us date, ~1 ~). For o~n sites us~ ~ ~ta. I~t ~ ~ls u~d ~ d~ment s~e eligi~l~ ~ lo~u~ u~d by ~1 disL to es~bl~h ~n~ M fr~ & ~ p~ ~ren. E. For enrolled sites, Form 1531 will be used to document e~igibilit~. If the enrolled site 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? ................................................... 4. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter II) .......................................... F'~Yes F-~No If Yes, give name of contracting organization: CiL7 of Denton ~ Monitoring Plan (SFSP Handbook, Chapter III): Enter date o! monitoring review to be conducted within: 5. Meal Service Period Information (SFSP Handbook, Chapter II): NUMBER OF MEAL, SERVICE TIME TYPES OF uE~.S EUGmL.E TO BE SERVED' BEGINNING ENDU, JG Breakfast A.M. Supplement Lunch 40 12:00 p.m. 1:00 p.m. P.M. Supplement Supper 7. Do you plan to feed children under one (1) year old? ..................................................................... k. JYes ~k~ No 8. Method of Food Preparation by Con~'acfing Organization (SFSP Handbook, Chapter II) J S~-P~,'~ v~ Using School Using Food Service Management ~ On Site [] Cenbal Kitchen ~ Food Authority [] Company (Includes All Year Contracts) II Organization that Is Serf-Prep 9. Indk:ale the Syslem to be used for the serving of meals end the supervisio~ of chadrefl during meal service, period. (SFSP HandbOok, Chapter II) r--I Cafeterta'elYle r--I Children are Seated ~ CMIdren Une Up I'"1 Meal Service I I and ere Given Meals I~1 and Pick Up Meals ! I Other:. 10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Chapter II): TITLE OF POSmON NO. IN PORTION ~PECIFIC FOOD $ERV1CE PROGRAM I~ITIE$ Site Su~egvisog ~ Supervise and assist dist=ibution o~ meals, montt~ and maintain meal temperature, site clean-up and other duties as assigned 11. Indicate what provisions will be mede for meal san,~e during periods of inclement weather. (SFSP Handbook, Chapter II) i~Meal Meal Sendce Will Be C~ncelled D Other: 12. If the site leeds ~marily homeless children, what methods ere used to ensure that money, food slamps, o~ In-kind sewines are not required for meals? N/A 13. Are meals delivered to the site? ........................................................................................... [] Yes [] No IF YES, COMPLETE ITEMS 14, 15, & 16. IF NO, FORM IS COMPLETE EXCEPT FOR CERTIFICATION AT BOTTOM. 14. Indicate the means of c,~mmunication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Chap. II) [~]Site Personnel Will Contact Administrative ~ Slta Personnel Will Communicate Staff, Who Will Contact Vendor I IDIrectly With Vendor 15. Will del'we~/be within one hour o! the food sen,ice period? (SFSP Handbook, Chapter II) ...................................... [-~Ye$ [] No If no, describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of set,ce. 6. If there is an excess of meals delivered, meals will be (SFSP Handbook, Chapter III) i-~ Stored In Refrigerator r-.~ Thrown Away ~I Returned to Vendor and Sewed the Next Oay I lattheSite I Ifor Dlspneal r"'lc)thec. CERTIFY that the information orj this form is .Iru~and correct to the best of my knowledge. I certify ~at this site has been visited and that ~as the capacity and facilities f,ef the meal ~)fv~ planned for the number of children anticipated. I know that deliberate misrepresentati(m c. ~,,thh~in/~/(nlo .m~atiq'n m/&y/J,~ait'ln ~rqg'A'~fon,.pnder applicable state and federal statutes. I city of De.ton 7s~,~u~,~of'c~,a~go.~t~.,~o. ' / ~ '~ Lloyd ltarrell 1'~ City Manager TEXAS DEPARTMENT OF HUMAN SERVICES Special Nutrition Programs A~essment Fee for USDA Commodities Summer Food Service Program May 1, 1995 to September 1, 1995 Name of Agency: City of Denton ~ ! .~. Address: Contact: Phone Number: To determine the assessment fee, complete the following: I divided by J J = I ~ Total number of Total days of operation ADP ~ participating children x .08 = [ ADP Assessment Fee Send a copy of this page with your payment, made payable to the Texas Department of Human Services, and submit by June 15, 1995, to: Texas Department of Human Services Financial Management Services (Y-906) P. O. Box 149030 Austin, Texas 78714-9030 Note: Also submit a copy of this page with your Form 1608. of Hum~ ~ SUMM~ ~OOD SER~CE PROGRAM APPLICATION AND AGR~M~ FOR RECEIPT OF USDA COMMODITIES City of Denton ~ (~ ~i~ ~) ~T~ No. ~ From APPOINTMENT OF THE AUTHORIZED RE~R~ENT~TIVE--T~e official who signs this fo~ m~t =p~lnt ~ lut~r~ repr~anta. t=tIve ~ g~en ~11 r~ll~ f~r ~11 m~er~ ~l~n~ to ~e recelp~ ~=~llng, storage, pmte~n, ~unt~ll~, ~ use of I ce~lfy t~ I ~e re~d t~e .greement on t~ ~=~ of t~ fo~ ~ t~at my slgn~ure ~elow ~knowl~ges i~ to ~mp~ with ~11 of t~e te~ ~ ~P~ of t~t ~greement. Th~ ~greeme~ s~all ~e In effe~ for ~ ~n~¢ ~n one ye~. It mly ~ ~e~ed at ~t~ ~dles' option for ~o ~d~lonal on.year ~er~ds. If ~e~e~, the applicant must u~ate all ~lnent Info.etlon ~ muet demo~t~te that ~11 ~onat~ f~ m~ during the pr~r ~ct period bas ~een ac~unted for. T~a ~graement may ~a te~n~ for ~e ~y e~er p~ u~n 30 notice. T~e official w~ slg~ this Application =nd Agreement ~umes tull respo~lbili~ foe ~mpli~nce wit~ t~e te~ =~ co~[Uo~s list- ed In t~e agreement. JUNE JULY AUGUST I NO. . NO. Oly~ Total I~ll &vlrige Totll M~II INFORMATION ~11 Be Aflln~e ~il Month A.I~I } Th~ M~n~ ', ~ AC~REEMENT THE APPLICANT FOR USDA. DONATED COMMO~ITI~.~ A~GREE~: 1. To ~ide by the in~t~s a~ ~u~t~ ~ by ~S and USDA for ~ng, ~ti~, and using ~s. 2. To ~ ~~ on~ to ~ne~¢ ~'~ in t~pl~N's ~bl~ f~ ~w~s ~tion. 3. To requ~t a~ accept ~s only in a~n~ ~t will ~ property st~ and fully 4. TO n~ ~11, t~e, ~ d~ of ~~, ~i~ ~m~l p~ of ~s ~ d~emm e~ pr~, 5. TO p~ a~u~e ~l~s ~d ~nel ~ ~, ~om, pmte~, a~ ,_~ c~s. 6. To ~ DHS ~ U~A ~ ~, at ~y ~ ~. t~ ~s ~ ~ a~ the ~l~s ~d riling a~ ~ 7. To ~y t~ ~ ~ ~ DHS ~ ~ ~ ~in~e ~ ~ ~ ~ ~ p~ ~ ~te ~w. · gins ~f~ t~ 3 ~r ~ i~i~, ~ ~ mu~ ~p ~ ~ ~ ~ ~ ~ 3 ~ ~ ~ ~ until all I~at~n, c~ ~ aud~ fi~i~ am ~. ~ ~ ~ c~ ~ ~ ~m b a a~ ~r in I~t~n, or w~n DHS a~ ~ ~m~ en~ ~o a ~n ~. ~ ~ ~a k~ ~ ~ns t~ ~inning date thm~h ~ eMi~ ~e ~if~ in ~ o~i~ ~~mm~; e~e~ am ~n~ 9. To ~mply w~h the ~uim~ of t~ ~n ~ a~ ~t~ ~ ~ 19~ ~Mi~ e~nt ve~t~n a~ mtenton of verboten ~ ~r ~y i~ua~ hired a~er ~e~r 6, 19~, ~ ~11 ~ ~y ~ or un~r th~ ~N~. 10. To ~ply ~h the in~m~io~ ~ r~u~t~ ~ by DHS ~r ~u~i~ r~l ~ ~1~ a~. 11. To mimbu~ OHS, a~ing to DHS' pr~u~, ~ any ~p~ d~ ~ ~ ~ d~t~ ~, or ~r any of, ~ da~ge to, ~t~ ~ ~L~ ~ t~ a~l~m's ~u~ or ~gl~e~. 12. ~t any m~ of ~ ~ ~y ~ ~ to ~ d~l~ f~ p~ ~~, a~ th~ rein~emem ~ at DHS' ~t~. 13. ~at any em~, m~, t~, or ~i~m by ~ of ~t~ f~ or ~t~ ~t~ fu~s, ~, or pro~, sMII ~ the ~pl~nt to ~ ~j~ to Fermi ~iMI F~. 14. CNil Righ~ (a) To ~mDly ~h ~R~ VI of the C~il R~Ms ~ of 19~ ~ubl~ ~w ~, ~ ~ of t~ ~il~t~ 1973 (Publ~ ~w 9~112). ~ ~ns ~h D~bil~s ~ of 1~ ~u~ ~w 101-~6), and all a~nts to each, a~ ~1 ~uir~ ~d by ~ ~u~ ~ pu~m to t~ a~s. In add,On, t~ ~m~or ages to ~p~ ~h TRM ~, C~er 73, of ~ Te~ ~n~mt~ C~. ~ pmv~ in paffi that no ~ns in the Unff~ S~tes sh~l, on t~ gmu~ of m~, ~r, ~t~l ~in, ~x, a~, d~il~, ~l~i~l ~1~ or minion ~ e~luded from ~i~t~ in. ~ den~. any a~, ~m. ~w~ ~ ~r ~ p~ by federal a~ funding, ~ ot~ ~ ~ to d~i~n. ~) To c~ply ~h Te~s ~d C~il S~t~ ~ ~19~. ~m~s 5.~ a~ 5.~ (m~ti~ to ~rkp~ce a~ ~emml~ gu~elines mga~i~ NOS and HI~. (c) To ~mpi~ date, ~i~in ~o~, a~ ~ ~ ~ ~uimd, to ~ eff~ enfo~e~ of the a~ve Ac~ and ~R a~h~ DHS ~d USDA ~1 dudng ~1 ~ h~ ~ mv~w s~h ~s, ~ and a~ounts ~ ~d to ~in ~n~ ~h the ~ ~. If t~e am any v~t~ of th~ ~eum~e, DHS and USDA ~ve t~ ~M to ~ekjud~l e~e~nt of th~ ~m~. ~ ~m~e ~ bi~i~ on the ~ s~, ~fem~, a~ ~ ~ ~ ~ ~ mce~ ~e~, ~ ~i~ ~n of any frffi DHS. ~e ~ w~ s~natum a~m on th~ c~ffi ~ ~ ~ s~n thffi ~um~e ~ ~ ~h~f ~ ~e ~um~ are g~en in ~m~mt~n of and ~ the pu~ of ~ining any a~ all f~eml flna~l am s~n~, g m~ ~d ~ of ~ml fu~, re~u~ e~u~. gram ~ ~t~ of f~eml p~. a~ ~terem in p~, t~ de~il of ~ml ~1, t~ ~ a~ ~ ~. ~d ~ ~ to u~, fermi p~ ~ intemm in s~h p~ ~ t~ ~m~i~ ~ ~w~ ~ ~e~ ~ ~ a ~i~l ~e~, or at a ~h ~ ~u~d ~r ~e pu~ of ~ ~ ~nt. or in ~n~ of ~ ~bl~ ~e~ to ~ ~w~ ~ such ~M, Ma~, ~ fum~i~ of ~ tO t~ ~m, or any ~~ ~ ~h ~eml fl~l ~ e~en~ ~ to the ~mm ~1~ by DHS. ~ i~lu~s ~y federal ag~nL ar~, or ot~r ~ntm~ wh~h h~ ~ o~ of ~ pu~ t~ p~n ~ c~ ~ e~e~ed in ml~e ~ t~ mpre~n~t~n a~ agreements ~de in th~ ~ ~ ~ APPLICATION FOR NON-PROFIT HUB STATUS (Non-Profit Organizations) :omplete this form end return it to the address shown at th~ ri~ht~ If yOUr orgah~ ,*tion q~lllflel II · Historically Underutilized Bualne~l (HUB) y~u will be ,la,Id on · HUB vendor Il·ting which Is ·cceued by Tlxa~ state Igen~isl lot ,rocurement of goods Ind ~ervlce$. SS No. Tex~ ray;; ID No. · ~.~,~"; of the _;J~__rd: Identify the ind~,_,~ on your governing ,.. G;ve · ,nm ._~=,~,,.,, ~ u,e =,.=., in which/ou wish to receive bid invitations. Incl~e C~ ~ I~m N°.. if ~- ~nfin~ °n ba~ ~ n~a~' ,. ITEM NO. OE$CP. IPllON 3. indicate wha~ geographic area(s) you are able to serve. (See map showing geographic areas.) 3 n~ck ti Iaddlno In iii emi'1' If bidding °ntY m certain Im&s' cucie IPP'~P'~"~ nU'T"~'-;~)* I []AU. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 23 24 25 ~ certify, under penalty of law, that the above and foregoing information is a full, true, and correct statement of the facts· '"]Please send me information on how to get on the General Services Commission bidders mailing list· (An annual fee is required.) Comments: Instn~¢tiona for Form 2066 APPLICATION FOR~NON-PROFIT HUB STATUS Fix is~ in c~3~TN~eting th~ Ipp#catJon, you may ~ (512) 450- :882. Aff'~ma~e Action InitJatJves/Civil Rights De~ Beginning ~ "ID No.,' CX)d~detl all items. If your Infon~ation has already been entered, please con'ect any eh-ors. Your iclen~Mn number ~ be one, of ~e.~pIIowing: - · your Tex~ TIx~umlmr 1~41gnecl by the Texas State Complro#er's · your Federal Employs. Numbs' issued by the Internal Revenue Sen4oe, · your Texas Payee~u4~ber as,lignecfby ~e Texas State Comptrollers Offise. 8pi=e. provide name~ ~ Infotmalkm on an a~e_~,'/~'~ed 8heeL IXYdmsed by the rote of Texas are described by a commodity code. The ~ three numbers represent the cie~ and ~e next two. the Item 3: Circle the number& of the areas o~ Texas, as shown on the map below, in which you can provide sefv~e____, or goods, ff yo~ ~efve the ~ Itata, check "AU- · Map ueed to determine area In Item 3: The authorized representative of your organization must sign and date the form. Include the representative's title. If you m'e interested in receiving infon'nation about being on the General Services Commission bidders mailing list, check the box indicated. The General Services Commission has the statutory responsibility for purchasing supplies, materials, services and equipment for the state, ~ncluding all state agencies. The commission mails bid invitations to interested vendors. An annual fee is required for be ng on the mailing list.