Child and adult care food program reimbursement claim sponsoring organizations of




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Wisconsin Department of Public Instruction

CHILD AND ADULT CARE FOOD PROGRAM

REIMBURSEMENT CLAIM—

SPONSORING ORGANIZATIONS OF
FAMILY DAY CARE HOMES

PI-1452 (Rev. 06-13)



INSTRUCTIONS: Use this form as a worksheet and submit the claim information via the internet by the 15th of the month following the month you are claiming for. Only submit this completed paper claim form if it is a 4th claim or if it is past 60 calendar days from the last day of the claim month. Keep a copy of this completed form for your files. If submitting a paper claim form, send to:

WISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION

ATTN: JACQUE JORDEE or RICHARD FAIRCHILD

FEDERAL AIDS AND AUDIT SECTION

P.O. BOX 7841

MADISON, WI 53707-7841

FAX: 608.267.9207

jacqueline.jordee@dpi.wi.gov or richard.fairchild@dpi.wi.gov




Collection is a requirement of PL 95-627.

Claims submitted more than 60 days after the end of the claiming month cannot be paid unless a special exemption is granted by USDA.






Agreement Number

     


Month

     


Year

    








GENERAL INFORMATION







Sponsoring Agency’s Name

     

Telephone Area Code/No.

     





Address Street, City, State, Zip

     








I. PARTICIPATION DATA











Tier I


Tier II
All Higher


Tier II
All Lower


Tier II
Mixed





A. Average Daily Attendance (ADA) In Homes

    

    

    

    




B. Number of Homes Claiming This Month

    

    

    

    




C. Number of Operating Days

  

  

  

  







Tier I

Tier II







Higher

Lower







D. Number of Breakfasts

     

     

     







E. Number of AM Snacks

     

     

     







F. Number of Lunches

     

     

     







G. Number of PM Snacks

     

     

     







H. Number of Suppers

     

     

     







I. Number of Evening Snacks

     

     

     







FOR DPI USE ONLY

Total Homes x Rates Equals




Total Meal Reimbursement










Administration










Advance Payment










Administration Balance Due










Total Payment







II. OPERATIONAL FUNDING—RECEIPTS/PAYMENTS







Amount

A. Operational Advances Received this Month 

$      

B. Operational CACFP Reimbursement Received this Month 

$      

C. Total Operational Receipts Line A + Line B

$ ,

D. Cash Payments to Homes this Month 

$      

E. NET DIFFERENCE Line C minus Line D

$ ,







III. ADMINISTRATIVE CASH RECEIPTS







Amount

Comments and Explanation

     


A. Administrative Advance Received this Month

$      

B. Administrative CACFP Reimbursement Received this Month

$      

C. Revenue for Administration from Sources other than DPI

$      

D. TOTAL Lines A, B, and C

$ ,




IV. ADMINISTRATIVE EXPENDITURES/COSTS




Accounting Basis:  Accrual  Cash

Amount

Explanation of Others Costs Per Item J. to Left

A. Administrative Salaries

$      

     

B. Administrative Benefits

$      

C. Administrative Supplies

$      

D. Office Rent and Utilities

$      

E. Insurance Expense

$      




V. CERTIFICATION




F. Contracted Services

$      

I CERTIFY to the best of my knowledge, that this claim is true and correct in all respects, that records are available to support this claim and that it is in accordance with the terms of the existing agreement.

G. Equipment Rental/Lease Expense

$      

Signature of Authorized Representative



H. Telephone Expense

$      

I. Dues, Subscriptions, or Memberships

$      

Title      

J. Other Administrative Costs Explain in Section to Right

$      

Date Signed Mo./Day/Yr.      

K. Travel Expense

$      

FOR DPI USE

L. Training Expense

$      




M. Total Expenditures/Costs Lines A through L

$ ,









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