Form FNS-742 School Food Authority Verification Summary Report

FORM APPROVED OMB #0584-0026
Expiration Date 10/31/2006

[INSERT STATE AGENCY NAME]

SFA ID#
SFA NAME

SCHOOL FOOD AUTHORITY
VERIFICATION SUMMARY REPORT

TYPE OF SFA

Public

SCHOOL YEAR

Private

-

According to the Paperw ork Reduction Act of 1995, no persons are required to respond to a collection of information unless it contains a valid OMB control number. The valid OMB number
for this collection is 0584-0026. The time required to complete this information collection is 6 minutes per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection.

I. Enrollment, Application, and Eligibility Information
(Pre Verification)

II. Results of Verification, by Application Type

1. Type of Free/Reduced Price Application Used

6. Type of Verification Used

Individual Student

Household

Report items 2 through 5 as of the last
operating day in October

Basic

Both
A.
All Schools

B.
Provision 2/3 Schools
WHICH ARE NOT
OPERATING A BASE
YEAR

2. Number of schools and RCCIs operating
the NSLP and/or SBP

Alternate-Random

Alternate-Focused

Items 7 through 11 are required
and are reported as of the date of
completion of the verification
process (see instructions). Item
12 is optional and is reported as
of February 15.

A. FREE
ELIGIBLE
based on
FS/TANF/FDPIR
Application
(Categorically
Eligible)

No Verificatons Performed
B. FREE ELIGIBLE
based on
Income/Household
Size Application
(Income Eligible)

C.
REDUCED
PRICE
ELIGIBLE

3. Number of enrolled students with access
to the NSLP (or SBP for SBP only schools)
A.
# of Students

B.
# of Approved
Applications

7. No Change

# applications
# students

4. Total FREE ELIGIBLE reported

# applications

4-1. # approved as FREE ELIGIBLE w ho are not
subject to verification (directly certified, homeless
liaison list, income-eligible Head start, pre-K
Even start, residential students in RCCIs,
non-applicants approved by local officials)

8. Responded,
Changed to Free

4-2. #approved as FREE ELIGIBLE based on
FS/TANF/FDPIR case number submitted on an
application (Categorically Eligible)

9. Responded,
Changed to
Reduced Price

# applications

4-3. # approved as FREE ELIGIBLE based on
income/household size information submitted
on an application

10. Responded,
Changed to Paid

# applications

4-4. # FREE ELIGIBLES reported for Provision
2/3 Schools WHICH ARE NOT OPERATING A
BASE YEAR

11. Did Not
Respond

# applications

5. Total REDUCED PRICE ELIGIBLE
reported
5-1. # reduced price eligibles reported for
Provision 2/3 schools WHICH ARE NOT
OPERATING A BASE YEAR

FNS-742 (2/04)

# students

# students

# students

# students
12. Reapplied and
Reapproved on or
Before Feb. 15

# applications
# students

Electronic Form Version Created in Jetform 5.01

INSTRUCTIONS FOR COMPLETING THE
SFA VERIFICATION SUMMARY REPORT
ALL SFAS WHICH OPERATE THE NATIONAL SCHOOL LUNCH PROGRAM (NSLP) AND/OR THE SCHOOL
BREAKFAST PROGRAM (SBP) MUST COMPLETE THIS REPORT ANNUALLY EXCEPT: 1) SFAs w hich ONLY
administer the program in Residential Child Care Institutions (RCCIs) w hich do not have day students; 2) SFAs w hich
claim for all schools based on claiming percentages established through a population survey; 3) SFAs w hich do not
have any free or reduced price eligible students.
I. Enrollment, Application, and Approval Information (Pre-Verification)
1. Indicate the type of application used for students w ho are applying for Free/Reduced Price Meal benefits.
Report Items 2 through 5 as of the last operating day in October.
2 - 3. Enter the TOTAL number of NSLP/SBP schools and the number of students w ith access to the NSLP (or the
SBP if the SFA does not operate the NSLP) for the SFA in column A. If the SFA has schools w hich are operating
under Provision 2/3 for lunch (or for breakfast if the SFA does not operate the NSLP) WHICH ARE IN A NON-BASE
YEAR, enter the number/enrollment of 1) the Provision 2/3 NON BASEYEAR lunch schools plus 2) any Provision 2/3
NON BASE YEAR schools w hich only operate the SBP in Column B.
4. In Column A, enter the TOTAL NUMBER OF FREE ELIGIBLE STUDENTS that the SFA reported as of the last
operating day in October.
4-1.In Column A, enter the TOTAL NUMBER OF STUDENTS approved as FREE ELIGIBLE w hose approval
is not subject to verification. This includes students w ho are directly certified based on information from
the FS/TANF/FDPIR agency, children on the homeless liaison list, income eligible Head Start, pre-K Even
Start, residential students in RCCIs, and non-applicants w ho are approved by local officials. DO NOT
INCLUDE the calculated number of free eligibles w ho are reported for Provision 2/3 schools w hich are not
operating a base year. These are reported in item 4-4 below .
4-2. In Column A, enter the TOTAL NUMBER OF STUDENTS approved as FREE ELIGIBLE based on a
FS/TANF/FDPIR case number w hich w as submitted on an application (Categorically Eligible Applications).
In Column B, enter the TOTAL NUMBER OF APPROVED CATEGORICALLY ELIGIBLE APPLICATIONS on
file.
4-3. In Column A, enter the TOTAL NUMBER OF STUDENTS approved as FREE ELIGIBLE based on
household size and income information submitted on an application (Income Eligible - Free Applications).
In Column B, enter the TOTAL NUMBER OF APPROVED INCOME ELIGIBLE - FREE APPLICATIONS on file.
4-4. Enter the TOTAL NUMBER OF FREE ELIGIBLES reported for Provision 2/3 schools w hich are not
operating a base year in Column A. (This number is determined by adjusting the number of free eligibles
in the base year for these schools to reflect current total enrollment.)
5. In Column A, enter the TOTAL NUMBER OF STUDENTS approved as REDUCED PRICE ELIGIBLE. In Column B,
enter the TOTAL NUMBER OF APPROVED REDUCED PRICE ELIGIBLE APPLICATIONS on file.
5-1. Enter the TOTAL NUMBER OF REDUCED PRICE ELIGIBLES reported for Provision 2/3 schools w hich
are not operating a base year in Column A. (This number is determined by adjusting the number of
reduced price eligibles in the base year for these schools to reflect current total enrollment.)
II. RESULTS OF VERIFICATION
6. Indicate the type of verification process the SFA uses to comply w ith the requirements of 7 CFR 245.6a.
7 though 12. Enter the results of the verification process BY TYPE OF APPLICATION APPROVAL. Items 7 through
11 are required, and are reported as of the date of completion of verification. For the purposes of this report
verification is complete:
for households w hose eligibility does not change: as of the date of the confirmation of eligibility by
a review ing official;
for households w hich do not appeal a change in eligibility: as of the first operating day follow ing
the last date for filing an appeal in response to a notice of change in eligibility;
for households w hich appeal a change in eligibility: as of the first operating day follow ing a
decision by the hearing official.
7. Enter the number of applications w ith no change in eligibility and the number of students on these applications,
for each application type.
8. Enter the number of applications for w hich the eligibility w as changed to FREE BASED ON DOCUMENTATION
PROVIDED BY THE HOUSEHOLD, and the number of students on these applications, for each application type.
9. Enter the number of applications for w hich the eligibility w as changed to REDUCED PRICE BASED ON
DOCUMENTATION PROVIDED BY THE HOUSEHOLD, and the number of students on these applications, for each
application type.
10. Enter the number of applications for w hich the eligibility w as changed to PAID BASED ON DOCUMENTATION
PROVIDED BY THE HOUSEHOLD, and the number of students on these applications, for each application type.
11. Enter the number of applications for w hich the eligibility w as changed to PAID BECAUSE THE HOUSEHOLD DID
NOT RESPOND, and the number of students on these applications, for each application type. NOTE: Report ALL
applications for w hich the household did not respond, even if the students on the application continued to receive
free or reduced price meals w hile being claimed as paid.
12. Enter the number of applications for households w hose eligibility w as changed to PAID as a result of verification
that resubmitted applications and w ere re-approved for either free or reduced-price meal benefits, and
the number of students on these applications, for each application type.