State/Local: D - SFA Reimbursement Claims Data

OMB Approval No.: 0584-0530

Approval Expires:

NSLP AND SBP ACCESS, PARTICIPATION, ELIGIBILITY, AND CERTIFICATION STUDY (APEC-II)

SFA REIMBURSEMENT CLAIM VERIFICATION FORM

TARGET WEEK FOR SAMPLED SCHOOL

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection is 0584-0530. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collected.

N SLP AND SBP ACCESS, PARTICIPATION, ELIGIBILITY,

AND CERTIFICATION STUDY (APEC-II)

SFA REIMBURSEMENT CLAIM VERIFICATION FORM

TARGET WEEK FOR SAMPLED SCHOOL

Number Serving Days:

Breakfast Lunch

| | | | | |

SFA Name:

SFA ID: |___|___|___|___|___|___|___|___|

School Name:

School ID: |___|___|___|___|___|___|___|___|

Date: | | | / | | | / | | |

MONTH DAY YEAR

Target Week From: | | | / | | | / | | | TO | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

IF CEO SCHOOL, ENTER REPORTED MEALS FOR FREE, PAID AND TOTAL ONLY

PART A: BREAKFAST
REPORTED TO SFA BY SCHOOL					REPORTED TO STATE AGENCY BY SFA
Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |					Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |
COMPLETE FOR PROVISION 2 OR PROVISION 3 SCHOOL IN NON-BASE YEAR ENTER THE CLAIMING PERCENTAGES USED:					BASE YEAR PERIOD USED:
| | | | % FREE	| | | | % REDUCED		| | | | % PAID		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH USED:
COMPLETE FOR CEO SCHOOL ENTER THE CLAIMING PERCENTAGES USED:
				| | | | % FREE		| | | | % PAID

PART B: LUNCH
REPORTED TO SFA BY SCHOOL					REPORTED TO STATE AGENCY BY SFA
Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |					Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |
COMPLETE FOR PROVISION 2 OR PROVISION 3 SCHOOL IN NON-BASE YEAR ENTER THE CLAIMING PERCENTAGES USED:					BASE YEAR PERIOD USED:
| | | | % FREE	| | | | % REDUCED		| | | | % PAID		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH USED:
COMPLETE FOR CEO SCHOOL ENTER THE CLAIMING PERCENTAGES USED:
				| | | | % FREE		| | | | % PAID

PART C:

INTERVIEWER: The number of meals an SFA claims for a school may differ from what the schools report to the SFA because the SFA makes an error or because the SFA is correcting an error in the school’s meal counts.

1. COMPARE BREAKFAST COUNTS AND CLAIMS. First for breakfast, compare the SFA claims against the school reports for each meal type (free, reduced-price, paid, and total) for the target week. [Or for CEO schools, free, paid and total for the target week]. If they differ, then check the SFA records to see if there are any notes in the file indicating that the SFA corrected the school breakfast counts and document in the space provided below under “COMMENTS.”

COMMENTS:

2. COMPARE LUNCH COUNTS AND CLAIMS. Next for lunch, compare the SFA claims against the school reports for each meal type (free, reduced-price, paid, and total) for the target week. [Or for CEO schools, free, paid and total for the target week]. If they differ, then check the SFA records to see if there are any notes in the file indicating that the SFA corrected the school lunch counts and document in the space provided below under “COMMENTS.”

COMMENTS:

Prepared by Mathematica Policy Research Page 0