2003-105· · S:\Our Documents\Ordinances\03~summer food service.doc
O INANCE NO.
AN ORDINANCE OF THE CITY OF DENTON, TEXAS, AUTHORIZING THE CITY
MANAGER TO SUBMIT AN APPLICATION UNDER THE NATIONAL SCHOOL LUNCH
ACT TO OBTAIN FUNDING FOR THE 2003 SUMMER FOOD SERVICE PROGRAM; IF
SUCH FUNDING IS GRANTED, THE CITY MANAGER IS AUTHORIZED TO EXECUTE
THE SLIMMER FOOD SERVICE PROGRAM AGREEIVIENT WITH THE TEXAS
DEPARTMENT OF HUMAN SERVICES AND EXECUTE A CONTRACT WITH THE
DENTON INDEPENDENT SCHOOL DISTRICT AND ALL ADDITIONAL DOCUMENTS
AND AGREEMENTS, AS REQLqRED; 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 Department of Human Services for the purpose of making
meals available to eligible children at the City's Summer Action Site programs; and
WHEREAS, pursuant to the grant, if received, the City will contract with the Denton
Independent School District to provide the meals at the various sites; NOW, THEREFORE,
THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS:
SECTION 1. 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
Service Program Agreement with the Texas Department of Human Services, a copy of which is
attached hereto and incorporated by reference herein, along with any other documents and
certificates necessary to obtain such funding.
SECTION 2. The City Manager is hereby authorized to execute a contract with the Denton
Independent School District, substantially in the form of the contract which is attached to and made
a part ofth/s ordinance for all proposes, to provide meals for eligible individuals at the various sites,
and such other documents and certifications as are necessary to carry out the 2003 Summer Food
Service Program, if such program is funded per the terms set forth in Section I above, and to handle
all fiscal and administrative matters relating to the application and the program.
SECTION 3. The expenditure of funds necessary to administer the 2003 Summer Food
Service Program is hereby authorized.
SECTION 4.
approval.
PASSED AND APPROVED this the /,~---6 day of
This ordinance shall become effective immediately upon its passage and
,2003.
EULINEBROC~MAYOR
ATTEST:
JENNIFER WALTERS, CITY SECRETARY
BY: ~//~/~A~
APP~VED A O L AL FORM:
HERBERT L. PROUTY, CITY ATTORNEY
BY: ~
PAGE 2
TEXAS
Department of
Human Services
COMMISSIONER
James R. Hine
MAY 1 3 2003
City of Denton Parks and Recreation
ATTN: Kathy Schaeffer
321 E. McKinney Street
Denton, TX 76201
RE: Approved Summer Food Service Program (SFSP) Application for Program Year (FY) 2003
TX: 0§1-1002
Dear Ms Schaeffer:
Your application for the Summer Food Service Program (SFSP) -has been approved for Program Year (PY) 2003.
The program number for your Summer Food Service Program contract is 061-1002. The program number identifies
your organization as a participant in the SFSP. The contract number for your organization's Special Nutrition
Programs contract is 7553006 , The contract number identifies your organization as a contractor with the Texas
Department of Human Services (DHS), Special Nutrition Programs. Both numbers are unique to your organization and
will be required to be entered on forms when filing a claim for reimbursement and when completing the renewal
documents each year.
The attached table (Attachment #1) identifies the program operation forms, the number of forms enclosed, and'
general instructions for completion, submission, or maintenance.
SFSP Sponsors are required to use the DHS program operation forms enclosed. Food service personnel must
document meal production each day. A sample form is offered to sponsors to document your program's meal
production. However, sponsors may use another form of choice that is an informational equivalent to the sample
form that is enclosed.
The program operation forms enclosed may be duplicated, as necessary. However, you can contact this office if
additional forms are needed.
Also enclosed you will find a list of addresses to use when mailing information to the DHS (Attachment #2). Please
follow the instructions on the list to ensure that claims, checks, correspondence, and any other information you mail to
DHS will be received in the correct office.
Sponsors should maintain, as part of their official contract files, copies of the forms submitted to DHS. Sponsors
must comply with the requirements for forms retention. The requirements for forms retention are specified in the
SFSP Handbook. If you have any questions, you can contact me at:
· Paul Jacques, Area Program Manager
Texas Department of Human Services
Special Nutrition Programs MAIL CODE: 128-9
1501 Circle Dr., Ste. 155
Fort Worth, Texas 76119
(817) 321-8100
Special Nutriton Programs * 1501 Circle Dr., Ste. 155 * Fort Worth, Texas 76119 * (817) 321-8100
Page 2
You are required to submit a Single Audit if your organization expends more than $300,000 in federal funds during the
organization's, fiscal year. Based on the information on your completed Form 1569, you are required to submit a Single
Audit on I,/[,~, for your organization's fiscal year 2003. Failure to submit a single audit or to meet audit
requirements ~an result in adverse action against your conb'act, up to and including termination. Requests for payment
for audits for any year in which less than $300,000 in federal funds is expended will not be approved.
The United States Department of Agriculture requires that we inform you on an annual basis of your appeal rights. You
have the dght to appeal any action by DHS that affects your participation in the SFSP or your SFSP claim for
reimbursement. Refer to Section 10 in your (~urrent SFSP Handbook or Section 8000 in the new SFSP Handbook you
will receive. Also enclosed is Part 6000 of the Fair Hearings, Fraud, and Civil Rights Handbook for details on filing an
appeal. Your request for an appeal must include a copy of the adverse action letter and must be submitted within 15
d~ys of any notification by DHS affecting your participation or claim and must be addressed to:
HEARINGS DEPARTMENT, W-613
TEXAS DEPARTMENT OF HUMAN SERVICES
P.O. BOX 149030
AUSTIN, TEXAS 78714-9030
· Thank you for your participation in the 2003 SFSP. We look forward to working with your organization in increasing
the number of children in Texas who eat meals this summer. If you have any questions, please contact me at (817)
321-8100.
Sincerely,
Raul Jacques
Area Program Manager
enclosures
State of Texas
County of Denton
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 City of Denton both of whom are local governmental entities authorized to enter
into interlocal agreements under Chapter 791 of the Texas Government Code. (Vernon 1994)
Whereas, the interlocal agreement contemplates the performance of filnction or services that
each party to this contract is authorized to perform individually.
Whereas, that the City of Denton is making payment under this agreement which it is funding
from payments from current revenue; whereas, the payments provided by the City of Denton are
in an amount that fairly compensates the Denton Independent School District for the services that
it is performing.
Witnesseth:
I. Provision of Meals
Denton Independent School Dislrict 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, Owsley Neighborhood, Optimist Club, Mack Park, Church of
Christ, Fairway Villas, Village East Apartments, Fred Moore Learning Center, Borman
Elementary, Lee Elementary, Wilson Elementary and Ryan High School.
Breakfast ...... $ 0.00 each Lunches ....... $ 1.90 each
Snacks ......... $ 0.00 each Supper ......... $ 0.00 each
II. Menu Records
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 assume that said meals meet the minimum requirements as to
nutritive value and content as outlined in the U.S.D.A.'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 daily number of meals delivered by type.
III. Retention of Records
These records must be reported to the institution promptly at the end of each week. Denton
Independent School District agrees also to retain records required under the preceding clause for
a period of three years and 90 days after the end of the contract period. If audits, claims or
litigation have not been resolved, all records must retain beyond the required time period until all
issues are resolved in accordance with the Summer Food Service Program Agreement between
The City of Denton and The Texas Department of Human Services.
IV. Compliance With Immigration Laws
The Denton Independent 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 perform labor or
services under this contract.
V. Audit
The Denton Independent School District agrees to allow for purposes of andit, examination,
excerpt, and transcription: the USDA, the Comptroller of the Uuited States, D.S. and any of
their authorized representatives to have access to any of the contractor's books, documents,
papers, and records that are pertinent to the contract.
VI. Energy Efficiency
The Denton Independent School District agrees to comply with the required mandatory
standards and policies concerning energy efficiency contained in the Texas Energy Conservation
Plan issued in compliance with the Energy Policy and Conservation Act (P.L. 94-163).
VII. Remedies For Breach of Contract
The Denton Independent School District agrees that except for small purchase contracts, it will
comply with and enforce provisions that allow for administrative, contractual, or legal remedies
if contractors violate or breach contract terms, and any appropriate sanctions and penalties.
VIII. Compliance With Labor Regulations
The Denton Independent School District agrees to be in compliance with Section 103 of the
contract Work Hours and Safety Standards Act (40 USC 327-330) as supplemented by the
Department of Labor regulations (29 CFR, Part 5). Under this Act, contractors must compute the
wages of mechanics and laborers on the basis of standard workday of eight hours and a standard
workweek of 40 hours. Work that exceeds the standards must be compensated at least 1½ times
the basic pay rate for overtime hours worked. These requirements do not apply to the purchase
of supplies or materials ordinarily available on the open market or contracts for transportation.
IX. Equal Employment Oppommity
The Denton Independent School District agrees to comply with Executive Order 11246 entitled
"Equal Employment Oppommity" as amended by Executive Order 11375 and as supplemented
in Depat tment of Labor regulations (41CFR, Part 60).
X. Compliance With Laws
The Denton Independent School District agrees to comply with all other applicable laws,
including without limitation, any additional applicable Federal Laws or regulations contained in
the Summer Food Program Agreement between the City of Denton and the Texas Department of
Human Services.
XI. Remedy For Breach
If the Denton Independent School District fails to provide services in accordance with the
provisions of this contract, the City of Denton may, upon written notice of default to the
contractor, immediately terminate the whole or part of this contract.
XII. Consideration
The City of Denton agrees to pay Denton Independent School District for all meals ordered on
daily basis at the rate agreed upon in this contract.
XIII. Term
The agreement shall be effective as of June 2, 2003 and shall have the same term as the Summer
Food Program Agreement between the City of Denton and the Texas Department of Human
Services. 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.
XIV. Venue
This agreement shall be interpreted in accordance with the laws of the State of Texas. Any
litigation filed with regard to this contract shall be tried in a court of competent jurisdiction
setting in Denton County, Texas.
IN WITNESS WHEREOF, the parties hereto have executed this agreement as of the dates
indicted below:
Agreed to this date 3 i i ! -t75
DISD Sponsor ~' ~
Title School Board President
Title: City Manager
Agreed to this date
Sponsor Of~
The location of the food preparation site will be:
Rivera Elementary School
701 Newton
Denton, Texas 76205
APPROVED AS TO LEG, p~L FORM:
ATTEST:
JENNIFER WALTERS, CITY SECRETARY
STATE OF TEXAS §
· COUNTY OF TRAVIS §
TEXAS DEPARTM]ENT OF HUMAN SERVICES
SPECIAL NUTRITION PROGRAMS
AGREEMENT
The Tcxas Dcparmacnt of Human Services, hereinafter referred to as TDHS,
AND
City o~ Denton, Texas, A Texas Municipal Corporation:
at 321E.'McKinney St., Denton, TX. 76201
hereinat~ referred to as the Contractor, do hereby make and enter into this contraCt, as required by the National School Lunch
Act and the Child Nutrition Act, as amended, and the following program regulations: thc National SchoOl Lunch Program (NSLP),
7 Code of Federal Regulations (CFR) Part 210; the Special Milk Program (SIvI~), 7 CFK Part 215; the School Breakfast Program
(SBP), 7 CFR Part 220; the Summer Food Service Program (SFSP), ?CFR'Part 225; and the Child and Adult Care Food Program
(CACFP) 7 CFKPart 226.
This agreement establishes or continues the fights and rasponsibilifies of TDHS and the Contractor pursuant to the Contractor's
participation in oneor more of the above named progrsm~ as stipulated herein, ff this agreement continues an existing agreement,
all existing terms, conditions,, liabilities and obligations of the parties under the prior agreement remain in full force and effect,
except to the extent that those terms, conditions, habflities and obligations conflict with this agreement, in which case this
agreement takes pregedence.
By signing this agreement, both parties are bound by its term~ and conditions fi-om its beginning effective date, or the beginning
effective date of any prior agreemenffs continued by this agreement, until terminated in aecordance with this agreement.
I.
MUTUAL AGREEMENTS
The Partics mutuallY agree;
A. If thc Contractor fails to provide services m accordance with thc provisions of this contract, TDHS may, up°n written n°tice
of default to thc Contractor, immediately terminate the whole or any.part of this contract, including refusal to pay claims for
reimbursement, and such termination shall not be an exclusive remedy but shall be in addition to any other rights and remedies
provided bylaw or under this contract.
B. If federal or state laws or other requirements are amended or judiciallY interpreted so that the continued fulfillment °f this
contract, on the part of either party, is substantially unreasonable or impossible, or if the parties are unable to agree upon any
amendment which would therefore be needed to enable the substantial continuation of the services contemplated by this
conWact then, the parties shall be discharged fi.om any ~5n-ther obligations created under the terms of this contract, except for
the equitable settlement of the respective accrued interest or obhgafions, 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 paxty 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 thi/ty (30) day period. Nothing in this
paragraph shall be construed to prohibit mediate cancellation pursuant to above paragraphs A and/or B.
· II.
CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT
A. The Contractor will comply with the apPhcable regulations for its designated program, as well as 7 CFR. Parts 245 and 250,
as amended, the Uniform Federal Assistance Regulation (7 CFR, Part 3015, as amended), Audits of State, Local
Governments, and Non-Profit Organizations (7 CFR 3052, as amended)and state policies and procedures as issued and
amended by TDHS. The Contrantor further agrees to perform as described in its application (including its Policy statement
and supporting documents, and approved amendments to the application) for participation in the designated program.
The Contractor aceupts final ~dmlnistrative and financial responsibility for food service operations i~ each school, summer
feeding site, and child and/or adult care facility, hereinafter referred to as a site, operated or sponsored by the Contractor. The
responsibility includes any audit exceptions or payment deficiency in the program covered by this contract, and all subcontracts
hereunder, which are found after monitoring or auditing by TDHS or USDA and will be responsible for the collections and
payback of any amount paid in excess of the proper claim amount.
C. Thc Contractor submits for TDH$ approval only those applications for sites which have delegated thc authority for the
oflmini-~al/on of food service operations to thc ConffactOl~ or which have executed subagreements with the Contractor for the
administration of food services operations.
D. Contractors participating in the NSLP agree
t. that the official si~ing the Claim for Reimbursement will be responsible for reviewing and analyzing meal counts
to ensure accuracy and compliance with federal .regulations
2. to enter into an agreement to receive donated foods as required by federal regulations, and
3. to price lunch as a unit
E. Contractors participating in the CACFP provide or accept responsibility for the provision of organized, non-residential child
day care and will immediately report to The Texas Department of Protective and Regulatory Services (TDPRS) Licensing or
Child Protective Services staff, any suspected violations of TDPRS Licensing standards or snspected abuse of children in
sponsored centers or day homes.
HI.
RECORD KEEPING,
A. The Contractor will keep financial and supporting documents, statistical records, and any other records pertinent to the services
for which a claim was submitted in the manner and detail prescribed by TDHS. The records and documents will be kept for
a minimum of 3 years and 90 days after the termination of the federal fiscal year for the relevant program. If any litigation,
claim~ or audit revolving these records begins before such period expfl'es, the Contractgr will keep the records and documents
for not less than 3 years and 90 days and until all litigation, elaim~ or audit findings are resolved. The case is considered
resolved when there is a final order issued in litigation, or a written agreement is entered into between TDHS and the
Contractor. The Contractor will keep records of non-expendable property acquired under the conlract for 3'years and 90 days
after final disposition of the property.
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 acces~
to all records of costs paid, even in part, by TDHS.
C.. The ContraCtor and its subcontractors will establish a methodto secure the confidentiality of records and other information
relating to clients in accordance with the applicable federal law, rules, and regulations, as well as the applicable state law and
regulations. The provision shall not be construed as limiting the Department's right of access to recipient case records or other
information relating to clients served under this contract.
D The Contractor certifies that the goods and/or servico(s) covered by this contract are designated to be used prior to, during,
and aider calendar year 2000 AD. The goods and/or service(s) will be operated during such time periods without error relating
to date which represents different centuries or more than one century.
¸IV.
CIVIL RIGHTS POLICY' COMPLIANCE
A. The Contractor agrees to comply with Title VI of the Civil Rights Act of 1964 (pUbhc Law 88-352) and all requirements
imposed by the regulations of the Department of Agriculture (7. CFR part 15), Department of Justice (28 CFR Parts 42 and
50) and FNS directives or regulations issued pursuant to that act and the regulations. Section 504 of the Rehabilitation Act
of 1973 (Pubhc Law 93-112), the Americans with Disabilities Act of 1990 ('Pubhc Law 101-336), Title IX of the Education
Amendments of 1972 (7 CFR part 15a), the Age Discrimination Act of 1975 (Pubhc Law 94-135), 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 Admini~Irafive Code. These provide in part that no person in the United'States
shall, on the ground of race, color, national origin, sex, age, disability, political beliefs, or religion be excluded from
participation in, or demed any aid, care, service or other benefits provided by federal and/ur state funding, o[ otherwise be
subjected to discrimination. The contractor also agrees to comply with Health and Safety Code Section 85.113 (relating to
workplace and confidentiality guidelines regarding AIDS and HIV).
The contractor hereby gives assurance that it will immediately take any measures necessary to effeetoate this agreement.
B. This assurance is given m cousideration ofand for the purpose of obtaining any and all federal financial assistance, grants and
loans of federal funds, reimbursable expenditures, grant or donation of federal property and interest in property, the detail of
federal personnel, the sale and lease of, and the permi~sien 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 program applicant by the TDHS. This
includes anY federal agreement, arrangement, or other contract which has as one of its purposes the provision of cash
assistance for the purchase of food, and cash assistance for purchase or rental of food service equipment or any other financial
assistance extended in rehance on the representation and agreements made in this assurance.
C. The Contractor agrees to compile data, maintain records, and submit reports as required, to permit effective enforcement of
the above Acts and permit authorized TDHS, USDA and FNS personnel during normal working hours to review such records,
books, and accounts as needed to ascertain comphance with the above Acts. If there are any violations of this assurance,
TDHS, USDA and FIgS have the fight to seek judicial enforcement of this assurance. This assurance is binding on the
Contractor, its successors, transferees, and assignees as long as it receives assistance or retainn possession of any assistance
from the department The person whose signature appears on this contract is authorized to sign this assurance on the behalf
of the Contractor.
D. A rehgious or charitable organization is ehgible to be a contractor on the same basis as any other private organization. The
contractor retain~ its independence from State and local governments, including the contractor's control over the definition,
development, practice, and expression of its charitable or religious beliefs. Except as provided by federal law, TDHS shall
not interpret this contract to require a charitable or religious organization to alter its form of internal governance or remove
religious art, icons, scripture, or other symbols. Furthermore, if a rehgious or charitable organization segregates the
government funds provided under the contract, then only the financial assistance provided by these funds will be subject to
audit. However, neither TDHS' s selection of a charitable or faith-based contractor of services nor the expenditure of funds
under this contract is an endorsement of the contractor's charitable or religious character, practices, or expression. The
purpose of this contract is the provision of services; no State expenditures'haw as their objective the funding of seetarian
worship, instructions, or proselytization.
A charitable or faith-based provider of services under this contract shall reasonably apprise all assisted individuals of the
following: "Neither TDHS's selection ora charitable or faith-based provider of services nor the eXpenditure of funds under
this contract is an endorsement of the provider's charitable or religious character, practices, or expression. No provider of
services may discriminate against you on the basis of religion, a religious belief, or your refusal to participate in a religious
practice. If you object to a particular provider because of its religious character, you may request assignment to a different
provider. If you believe that your fights have been violated, please discuss the complaint 5vith your provider or notify your local
TDHS Special Nutrition Programs office.
Section 104 of The Personal Responsibility and Work Opportunity Reconciliation Act of 1996.42 U.S.C. § 604a, sets forth
certain additional rights and responsibilities for charitable and faith-based providers of services, certain additional rights of
assisted in~viduals, and certain additional responsibilities of TDHS to these providers and assisted individuals. This contract
is subject to those additional rights and responsibilities.
TDH$ CLAIMS PAYMENT
TDHS will, subject to the federal appropriation and availability to TDHS of sufficient funds for the applicable program,
make program payment to the Contractor in accordance with the texms of this agreement. No reimbursement shall be made
for performance under this agreement occurring prior to (a) the beginning effective date of this agreement or (b) a later
date established by TDHS based on the date of receipt of a fully executed copy of this agreement.
B. In accorttan~ with Section 403.055(h) of the Government Code, as added by Act of May 19, 1999, 76th Leg. ILS., ch.
583, Sec. 1, 1999 Tex. Seas. Law Set. 3125 ('Vernon), any payments owing to the contractor under this contract will be
applied towmd elimination of the contractor's indebtedness to the state, delinquency in payment of taxes to the state, or
delinquency in payment of taxes that the Comptroller administers or collects until the indebtedness or delinquency is paid
in full. This clause does not apply if federal law requires payment to be made to the contractor for goods and services
provided in support of any of the USDA child and adult nutrition program~, and may not apply ff federal law conditions
the receipt of the money for these goods or services to the state on the basis of payment being made to the contractor.
VI*
IMMIGRATION
Ti~e ContractOr agrees to comply with the requl~xnents of the Immigration Keform and Control Act of 1986regarding
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. · '
CERTIFICATION
A. Regarding Debarment, Suspension, Ineligibility, or Voluntary Exclusion For Covered Contracts - The conUactor certifies,
by execution of this agreement, that neither it nor its principals is presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded fi.om participating in this contract by any federal depurm~ent or agency or by
the State of Texas. By making this certification the contractor agrees to the following terms:
The above certification is a material representation of fact upon which reliance was based when this contract was
entered into. flit 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 State
Department of Agriculture or other federal department of agency, or the Texas Department of Human Services may
pursue available remedies, including suspension and/or debarment.
'The contxactor shall provide unmediate 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 be'come erroneous by reason of
changed circumstances.
covered contract, debarred, suspended, ineligible, paPacipant, person, prmcxpal, 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 defined in the attachment.
· 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 fi.om 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
Deparmaent of Human Services, as applicable.
CERTIFICATION
(Continued)
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 all solicitation for all covered subcontracts.
A contractor may rely upon a certification of a subcontractor that it is not debarred, suspended, inehgible, or
voluntarily excluded from the covered contract, unless it knows that the certification is erroneous. A contractor must,
at a rnlnim~rn, obtain certificates fi.om its covered subcontractor upon each subcontractor's initiation and upon each
renewal.
7. Nothing contained in ali the £oregning shall be cousmied to require establishment o£ a system o£ records in order to
render in good,faith the 8ertification 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 anthorized under paragreph 4 of these terms, if a contractor in a covered contract knowingly
enters into a covered subcontract with a person who is suspended, debarred, inehgible, or voluntarily excluded from
participation in this transaction, in addition to other remedies available to the federal government, Department of
Health and Human Services, United States Department of Agriculture, or other federal department or agency, as
apphcable, and/or the Texas Deparmaent of Human Services may pursue available remedies, including suspension
and/or debarment.
B. Regarding Federal Lobbying - This certification applies only to this contract and is a material representation o£ fact upon
which rehanee 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 behef, that:
· 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 fedei'al contract,
the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, or the
extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative
agreement.
Il'any funds other than federally appropriated funds have bean paid or will be paid to any person for influencing or
attempting to influence an officer or employee Of any agency, a member of Congress, an officer or employee 9f 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, "Disalosure Form to Report
Lobbying," in accordance with its instructions.
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. . .
C. The contractor certifies that if it is a corporation, it is either a for-profit corporation that is n°t dehnquent in its franchise
tax payments to the State of Texas, or is a non-profit corporation, or is otherwise not subject to payment of franchise taxes
to the State of Texas.
D. The contractor certifies that all information submitted pursuant to this agreement is true and correct. The contractor
understands that the dehberate misrepresentation or withholding of information is a violation of. this contract and may
result in prosecution under applicable state and federal Statutes.
E. Under Sectaon 2M.006, Fanaily Code, the vandor or ~pphcant certifies that the mdiwdual or business entity named m thi
contract, bid, or apphcation is not ineligible to receive the specified grant, loan, or payment and a~knowledges that this
contract may be terminated and payment may be withheld if this certification is inaccurate.
VIII.
EFFECTIVE DATE AND SIGNATURES
, "
, '.
The parties hereto in their capacities stated, affix their signatUres and bind themselves for the faithful performance of the
terms of this contract pursuant to' participation in the following program or programs:,
~ National School Lunch Program
School'Bteakfast Program
Special Milk Program
n Child and Adult Care Food Program
o Swnmer Food Service Program
City of n",nrnn
Name of Contracting Organization
(please print or type) ",,' , '
f e board of directors
or other official who s been authorized to sign'
contracts on behalf of the contracting organization.
Mike Conduff
Name of Official Signing
(please print or type)
City Manaqer
'Title of Official
(please print or type)
TEXAS DEPARTMENT OF HUMAN SERVICES
By:
1&'103
until terminated.
Date:
I-dl r-/63
Approved for Form by aGe: Si\1llature on file
Revised May 2001
APPROVED AS TO FORM:
crtv ATTORN
CITY OF D
BY:
Rp~' ~8 03 09:0la
S908 ~£
p.5
Tr-7~.-~ DEPARTME, NT OF H'UMAN
AMENDMKNT (Al
TO THE SPECIAL NUTRITION PROGRAMS AGREEMENT
Th= Tcxa~ Dnponment olr Huma~ Ser~i~.~ hcreinal'~r deslenate~ the Department,
(Name otC, one'acting Or~a~izmlon)
ltcr~iooite:r dcsJ~natod ~h; C~l~tan en/e~ ~nm · Sp¢;;al Nut~tion Pto~ a~em~t ~i~ fs effe~i~ until reginald.
C~t~tor M~ ~e ~p~t h~eby ~gr~ to ~e ~o[Iowing ~cndment lo ~¢k s~cnt.
A I;mitcd English proficiency clause is ~dcd ~l[owing the ctosin8 p~ph und~ Ag title: ' IK ClYlL RI~T~
COMPL~C~ in ~c ~m~, ~c cl~
wi~ limited En~lish pro~eiea~ a~ eff~i~e[y in~orm~ and ~n effec~ely ae~icip~te in and ~neflt
"Thin ~aragraph is pursuant to ~2~2.903 of the Go~ernment Code. Any pa~men~ e~in8 to ~e eon~a~or
contract will be aepli~ tows~ ~iminaflon or the contractor's indebt~n~ to the Itlte, delinquen~
or delinqaeacy b paid in
/
~r o~het o~ci~ who h~
/,'
~~n coe(~ ~ behalf of ~he contain& o~izadan.
Kathy Schaeffer
Youth/Teen Services Manaqer
Tirl~ o~Offi~zl
rovokzd, suspended, or
APR 2 2, 2U03
4/15/03
Da~c
Si~nal~re · D[~ Ro~gvc .
Da-~' ~itlc Of mC
gO'd 9g:8 £00~ g~ Jd~ ggos-I~£-iIS:xex IRX NOlli~l(~q q~ID~dS
Form 4.508
May 2000
SPECIAL NUTRITION PROGRAM
CERTIFICATE OF AUTHORITY
This is to certify that the following person(s):
Name of Authorized Representative (please type erp#nt) Titie
Michael A.. Conduff C~t.y Manager
Signature-Authorized Rela~en~tive
~f Authorized Representative (please type orpdnt) Title
Kathy Schaeffer / If..,._._ Yout,~Teen Services Mgr
8ignature--A'uttt~ed Representa/vev
is (are) designated as an Authorized Representative of
Name.of Contracting Organization
City Of Denton
Address (Street, C~ty, State, ZIP)
321 E. McKinnev St.. Denfnn~ T~
76201
The representative(s) designated above, and mysslf, acknowledge that each is individually authorized on behalf of
the contacting organization to make written agreements with the Texas Depsr~ent of Human Services to operate a
food program, to sign documents or reports about the agreement, and to present claims for reimbursement, when
appropriate, to the department.
By signing this document, we certify individually and collectively that to the best of o~r knowledge and belief, all
documents submitted physically or electronically on behalf of the above named Contracting Organizaben pursuant to
our pa~ctpafion in any and all programs administered by Special Nul~tion Programs, TDHS, are/will be true and
correct in all respects, tflat they are~vill be completed according to the terms and conditions of existing agreements
including amendments, that records am/will be available to support any and all claims, and that we will not submit
claims (excluding amended/adjusted claims) for goods or services for which we have already reoeived payment. We
recognize that we are fully responsible for any excess amounts which may result from errors made in relation to the
completion and submission of claims. We are also aware that deliberate misrepresentation er withholding of
information may result in prosecution under applicable state and federal statutes.
Name of Official of Contracting Agency (please type orp#nO Title .
Michael. A. Conduff ~ l{ City Manaqer
DELETED ALrTHORIZED REPRESENTATIVES: A contracting organization may not have more than three (3)
Authorized Reprssentet]vss, Including the Official of the Cenbacting Agency. If you are replacing or deleting an
Authorized Representative, list the name(s) of the individual(s) to be removed as Authorized Representative(s) below:.
Name of Deleted Representative Name of Deleted Representative Name of Deleted Representative
FOR DHS USE ONLY
C4~i~dCt NO.
Date Received
PROGRAM YEAR 2003
SUMMER FOOD SERVICE PROGRAM
CURRENT NON-SCHOOL SPONSORS
APPROVAL DOCUMENTS
1506 SUMMER FOOD SERVICE I Retain for your agency's SFSP
PROGRAMS APPLICATION files.
FOR PARTICIPATION,
Attachments A and B
1507 SUMMER FOOD SERVICE I Retain for your agency's SFSP
PROGRAM SITE files.
INFORMATION
1485
(February 1997) SUMMER FOOD SERVICE 3 Submit to Contract Manager prior
PROGRAM BUDGET to making significant changes in
AMENDMENT budgeted costs. Refer to Policy
Alert 2001-5 and Notice 2001-7 for
information about your budget.
1532 CLAIM FOR 4 Submit completed claims to SNP
(November 2002) REIMBURSEMENT (Special Financial Services, Y-906.
Nutrition Programs)
1514 CLAIM FOR 4 Complete for each cJaim
(October 2000) REIMBURSEMENT submitted. Retain on file.
WORKSHEET (Summer
Food Service Program for
Children
1557 MONITOR SITE REVIEW 3 Complete one form per site.
(January 1999) (Vended Programs) Sponsor maintains forms for
review by DHS and USDA.
1558 MONITOR SITE REVIEW 3 Complete one form per site.
(January 1999) (On-site Preparation) Sponsor maintains forms for
review by DHS and USDA.
1566 SUMMER FOOD SERVICE 3 Completion required. Sponsor
(January 1999) PROGRAM MONITOR SITE maintains forms for review by
VISIT DHS and USDA.
1568 RECORD OF RECYCLED 3 Completion required. Sponsor
(August 1998) FOOD maintains forms for review by
DHS and USDA.
1601 BENEFICIARY ETHNICITY 3 Completion required. Completed
(February 1991) DATA forms maintained by sponsor.
Civil Rights Posters: "And I poster of each per site Required posting of all 3 postern
Justice for All", Liberty Bell* at every site~
English, Liberty Bell-Spanish
Fair Hearings, Freud, and Reference information regarding
Civil Rights Handbook, Part 1 procedures for contract appeals.
6000 - HEARINGS UNDER Review and retain for your files.
ADMINISTRATIVE
PROCEDURES ACT
SFSP Program Information I Set Reference for your information
Matsrtals and use.
Page 4
MAILING ADDRESSES FOR
TEXAS DEPARTMENT OF HUMAN SERVICES
Mail to field office:
Raul Jacques
Area Program Manager
TEXAS DEPARTMENT OF HUMAN SERVICES
SPECIAL NUTRITION PROGRAMS, MAIL CODE 128-9
1501 C;rcle Dr., Ste. 155
Fort Worth, Texas 76119
Mail Claims for Reimbursement to:
TEXAS DEPARTMENT OF HUMAN SERVICES
FINANCIAL SERVICES SECTION
SPECIAL NUTRITION PROGRAMS, Y-906
P. O. BOX 149030
AUSTIN, TEXAS 78714-9030
Mail all checks and/or cashier checks to this agency to:
REBECCA COFFIELD
FINANCIAL SERVICES SECTION
SPECIAL NUTRITION PROGRAMS, Y-906
TEXAS DEPARTMENT OF HUMAN SERVICES
P. O. BOX 149030
AUSTIN, TEXAS 78714-9030
To be assured of proper credit to your contract, we request that the following information be submitted along
with payment:
Name of your organization
Program contract number (TX)
Program for which the payment is for, and
Month and year of service for which payment is for, and
Type of payment (i.e., claim overpayment, advance return, etc.)
Apr'-28-O3 O2:44P Denton Par'ks and Rec.
Texas Depsrtmsnt
:ity of Denton
321 E. McKinney St.. Denton, TX 76201
940 349 8384
SINGLE AUDIT IDENTIFICATION DATA
For Pr~ram Year 2003
(SNP Use Only)
Ka~y Schae~er
9/30103
~--~ Nan-Profit [] Govemmenbl
P.OP
March 2001
Check the appropriate box(ss) to indicate Ihs type(s) of program(s) in which you currently participate or for which you are applying:
[] A - National School Lunch
[] [] - Charitable Institutions
[] C :Area Agency an Aging
]G - Summer Camps
r-'IH - Summer Food Serwce
~--~J - Jails
[] I - TEXCAP
[] CS - Commodily Supplemmtla~ Food Prog.
PROGRAM NOS,
CASH REIMSURSSMENT PROGRAMS
[] AD - Adult Day Care
[] BL- National School Lunch/Breakfast TX -
[] CC - CACFP Center TX -
[] OH - CACFP Day Home TX -
[] SF - Summer Food TX - 061-1002
[] SM - Special Milk
[]TE-TEXCAP
[] CS - Commodity Supplemental Food Prog,
TX-
TX-
I'X-
Give the source and amount of any federal funds that your agency expends other than from those programs listed above:
[~ SINGLE AUDIT EXEMPTION - I certify that I am not required to submit an audit under the Single Audit Act for tho following reason(s):
[El , sm · for-profit organization. [] , expend lass than $3OO.gOO annually in total federal hJnding.
[~ SINGLE AUDIT ASSURANCE - I undersland tha'i it I meet the requirements of Ihs Single Audit Act, I wdl agree to submit an audit as
a condition of eligibility to participate in the Special Nuthtion Programs, and that failure to do so as required could result in adverse
scUDs, including the withholding o! my clmm for reimbursement payments and tan'nineties of my contract. I also understand Ihat if I am
a private non-profit organization subject to the requirements of the Single Audit Act and have a financial audit performed annually, I
must also. o~in a sln_~Je audit on an annual basis,
-
I
~KaihynthV SCha~.fferSc softer IYouth/'reen Services Manager
Texas Depar~nent
of Human Services SUMMER FOOD SERVICE PROGRAM FOR DHS STAFF ONLY
Contract No. TX No.
APPLICATION FOR PARTICIPATION
Give as much information as possible. Attach I Eft. Data//,O
additional sheets If needed; Identify each ---
organization.attachment with the name of the contracting Approved ForF_~. Breakfast [] A.M. Supp. [] Lunch [] P.M. Supp. [] Suppar
SECTION I - SPONSOR INFORMATION
CoMmcttng Organization Name
City of Denton
Mailing Address (Street or P.O. Box, City, State, ZIP)
321 E. McKinney St., Denton, TX 76201
Texas ID No.
17560005146015
Telephone No.
940-349-8125
Form ¶506/March 2001
[] NI
HoUIne No.
940-349-8278
Street Address (if different) E-mail Address
n/a Kathy.Schaeffer@cityofdenton.com
Name of Administrator 'l'ltta
Kathy Schaeffer Youth/Teen Services Manager
Name of SFSP Contact Pemon Telephone of Contact Person (include Ama Code)
Kathy Schaeffer (940) 349-8125
A. Contractor Classification (Check all that apply):
[] National Youth Sport~ Program [] Residential/Nonresidential
Summer Camp
[] School Food Authority [] Continuous Calendar
School Year
[] Unit of Government-Contractor certifies that all food
service sites are operated directly by the contractor.
[] Private Nonprofit
B. Is your program a year-round program? ........................................................................................................... . ........... ..:... [] Yes [] No
C. Type of Contractor:
[] Public Entity
Is your agency considered to be state owned/operatad? ............................................................................................ [] Yes [] No
Do you deposit your program reimbursement directly into the State Treasury? ........................................ [] NIA [] Yes [] No
Do you deposit your program reimbursement into a local bank? ............................................................... [] N/A [] Yes [] No
If yes, is it direct deposit? ..................................................................................................................................... [] Yes []. No
[] Private Nonprofit Organization-Tax-exempt status established. Attach letter of detarminat/on (IRS 501-30) of tax-exemPt status from IRS.
Do you deposit your program reimbursement into a local bank? ............................................................... [] NIA [] Yes [] No
If yes, is it direct deposit? ..................................................................................................................................... [] Yes [] No
D. Does the organization provide an ongoing year-round service to the community that is to be served by
the Summer Food Service Program (SFSP)? ................................................................................................................... [] Yes [] No
If 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
E. Does the organization expend $300,000 or more in federal funds yeady? ....................................................................... [] 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.
APR 2 gO03
SECTION ti - BUDGET
A. Estimate all SFSP costs which will be claimed for reimbumement for the program year:
1. PROGRAM YEAR
ESTIMATED OPERATIONAL COSTS COSTS
Program Labor ' 8,704
.. 971
Fringe Benefits
Food 47,000
350
Non-food Supplies
Utilities
Rent
Equipment Use Fee
Rental of Equipment 2,800
Rate per mile
Transportation !}
Other (specify);
600
gas
Other (specify);
drug tests 250
Other (specify);
400
coolers
TOTAL 1: 61,075
Form 1506
Page 2.
2. PROGRAM*YEAR
ESTIMATED ADMINISTRATIVE COSTS COSTS
Administrative Labor
(Management, Monitor, Clerical) 4500
Fringe Benefits 372
Rental of Office Space
Utilities
Office Supplies 100
Office Building Maintenance
Equipment Use Fee
Audit Fees
Legal Fees
Rate per mile.
473
Transportation I~ .365
Other (specify);
cell phones 450
Other (specify);
TOTAL 2: 5485
B. Indicate projected income to the food service from all sources other than SFSP reimbursement. Identify exactly the costs this income
will cover. (Do not include state or federal funds.)
Source of income VVill be used for:.
Source of Income
Will be used for:
SECTION III - MANAGEMENT PLAN
A. List administrative level personnel who will be responsible for management and monitoring of the SFSP. (Do not include site supervisors,
cooks, janitors or other personnel involved in on-site food service.)
TITLE OF POSITION NUMBER IN SPECIFIC FOOD SERVICE PROGRAM DUTIES
POSITION
Conducts training, monitors sites, prepares reports, coordinates
Program Director 1 food service.
Coordinator 1 Assists supervisor with duties
Form '~506
Page 3 ·
B. Are children charged separately for meals? ..................................................................................................................... [] Yes [] No
if yes, complete Form '~606, Attachment A (page 2), and submit with this application.
C. Do you want to receive advance payments?
For Operational Costs? [] Yes [] No For Administrative Costs? [] Yes [] No
D. if meal service is self-preparation, do you want to receive commodities? ........................................................................ [] Yea [] No
If yes, Form 1608, Application and Agreement for Commodities, must be completed and returned with your SFSP application.
SECTION IV - PROGRAM OPERATION
A. 1. Beginning and Ending Dates of Meal Service :, A.2. Number of Sites
FROM: June 2, 2003 TO: August 1, 2003 Ip 13
B. List dates and topics of SFSP training:
DATES TOPICS
' 5/29/03 Site supervisors and monitor training on S.F.S.P. guidelines and Civil Rights Training
C. is the organization currently contracting with a year-round food service management company? ................................... [] Yes [] No
If yes, submit a copy of your procurement procedures, bid, contract, and all amendments; skip item D. If no, complete item D.
D. Is the organization planning to contract with a food service management company? ....................................... ...........' .... [] Yes [] No
If yes, and the contract will exceed $10,000, attach a copy of the invitation to bid. Also give:
Date of Bid Publication Place of Publication Date of Bid Opening Time of Bid Opening
Is bid expected to be $100,000 or mom? .t. If yes, give place of bid opening:
[] Yas [] .o
Also, attach a copy of a minimum 11 -day-cycle menu including all specific menus to be used.
E. Attach a copy of the letter which has been (or will be) sent by the organization to the Health Department notifying them of intent to
operate a Food Service Program at the site(s) indicated on the attached Site Information sheet (Form 1507).
F. Are you implementing the option to allow off-site consumpfion of food? ................... [] All Sites [] Some Sites [] No Sites
SECTION V - ASSURANCES
A. Free Meal Policy Statement
1. The contracting organization assures the Texas Department of Human Services (DHS) that ali children at the sites described on the
Site(s) Information Sheets for the Summer Food Service Program will 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 beliefs. No
separate charge will be made for any meal except in accordance with attachment A of this application.
2. The contracting organization assures DHS that, if It is sponsoring camps or other enrollment programs:
· The contracting organization has or will obtain family size and income data about all children whose meals will be reported as free
or reduced-price; and
· The chiidran claimed as free or reduced-price meet the current family size and income standards set by the United States
Department of Agriculture, DHS Form 4504, Standards for Determining Free and Reduced-Prfce Eligibility.
3. If the contracting organization is sponsoring a camp or other enrollment program that charges separately for meals, the contracting
organization has read Attachment A to this application, "Additional Assurances for Camps and Other Enrollment Programs that
Charge Separately for Meals," and assures DHS that all raquiraments have been or will be met.
200:1'
Form 1506
Page 4
B. Public Release
1. The contracting organization will make efforts to ensure that the local news media will make a public announcement of the program
and will supply them with a news release.
If the contracting organization is sponsoring a camp or other enrollment program, this release must contain, at a minimum, a list of all
approved sites, a list of the current standards for determining free and reduced price eligibility, and the following statement:
"The (Name of the omanfzafion) announces the sponsomhlp of the Summer Food Service Program. Income
ellgibtiity will be based on family size and Income using the Standards for Determining Free and Reduced-Price Eligibility,
provided by the United States Department of Agriculture. Meals will be provided at the site(s) listed. People who are eligible
to participate In the program must not be discriminated against because of race, color, national origin, sex, age, disability,
religion, or potitlcel belief. Anyone who believes that they have been discriminated against should write Immediately to:
Director, Civil Rights Division, MC W-206, Texas Department of Human Services, P.O. Box 149030, Austin, Texas 78714-9030
or the Secretary of Agriculture, Washington, D.C. 20250. NOTE: Discrimination complalnta based on religion or political
· beliefs must be referred onlyto the Director, Civil Rights Division, Texas Department of Human Services."
For all other programs, the announcement must contain, at a minimum, a list of all approved sites and the following statement:
"The tName of the omanization) announces the sponsorship of the Summer Food Service Program. Meals
will be provided at the sita(s) listed. People who ara eligible to participate In the program must not be dlscrimlnatsd against
because of race, color, national origin, sex, age, disability, religion, or political belief. Anyone who beltaves that they have
been discriminated against should write Immediately to: Director, Civil Rights Division, MC W-206, 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."
2. This public release was or will be published in the following news media outlet(s):
NAME OF MEDIA OUTLET DATE OF RELEASE
Denton Record Chronicle 5/16/03
KNTU 5/16/03
Marcus Cable 5/16/03
NAME OF MEDIA OUTLET DATE OF RELEASE
City Cable Access Channel 5/16/03
3. Attach a copy of the contracting organization's public release statement as submitted to the news media and any other materials used
to publicize the program's availability and nondiscrimination requirements.
SECTION Vi - WAIVER REQUESTS (Check all for which you are applying, submit appropriate waiver request form and documentation.) [] Waiver to operate more than 25 sites (Nonprofit organizations only.)
[] Waiver of the time restrictions for meal servlca at migrant sltee.
[] Waiver of the 15 consecutive school day requirement for year-round school program sites. APR
[] Waiver of the first-week site visit requirement (School Food Authorities only). ~, 2 -~00,~
SECTION VI - CERTIFICATION (see Form 1506, Attachment B)
I certify that the information on this application Is true and correct to the best of my knowledge. I certl~ that reimbursement will be
claimed only for app~ved meals served t~llglble children during the hours they are In attendance at approved sites. I know that
deliberate misrepl:e~eentation or wlthholdl~;~ of Information may result In prosecution under applicable state and federal statutes.
Name (pleas~ type or. dp,~ / ij 'rifle
Kathy Schaeffer / Youth/Teen Serv ces Manager
FOR DHS USE ONLY
[~ APPROVED [] DENIED (reason):
Slgnat u re. Offiaa'~ o f ContinUing O~ganizaflon
Date