Child and adult care food program




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Wisconsin Department of Public Instruction

CHILD AND ADULT CARE FOOD PROGRAM

REIMBURSEMENT CLAIM
(At Risk Afterschool Programs and
Emergency Shelter Components)

PI-1489-B (Rev. 12-15)



INSTRUCTIONS: Use this form as a worksheet and submit the claim information via the internet within 60 calendar days from the last day of the claim month. Only submit this completed paper claim form if it is older than 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

FEDERAL AND STATE GRANTS PROGRAM

PO BOX 7841

MADISON, WI 53707-7841

FAX: 608.267.9207

jacqueline.jordee@dpi.wi.gov
Claims submitted more than 60 days after the end of the claiming month cannot be paid unless a one-time exception is approved by DPI.




Collection of this information is a requirement of PL 95-627.




Agency Code

     


Claim Month

     


Claim Year

    





Sponsoring Agency Name

     


Address Street, City, State, ZIP

     


Telephone Area/No.

     








I. CHILD AND ADULT CARE FOOD PROGRAM ENROLLMENT DATA







1. Total Enrollment / Total Eligible Children

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II. PARTICIPATION DATA







2. Number of Sites*

   


3. Number of Days of Service

     


4. Average Daily Attendance

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Breakfasts

AM Snacks

Lunches**

PM Snacks

Suppers**

Additional Snacks

Second Lunches**

Second Suppers**

Total




5. Number of Meals Served

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0







III. CERTIFICATION







I CERTIFY, to the best of my knowledge, this claim is true and correct in all respects; that records are available to support this claim; that it is in accordance with the terms of existing agreements(s); and that payment, therefore, has not been received.




Signature of Authorized Representative



Title

     


Date Signed Mo./Day/Yr.

     








DPI USE Only







Meal Reimbursement

$


Cash in Lieu of USDA Foods

$


TOTAL

$





Voucher Number

Payment Date Mo./Day/Yr.

* If two or more sites are operating, complete page 2

**Cash in lieu of USDA foods will be paid on these meals.







IV. SITE PARTICIPATION SUMMARY
To be completed only if two or more sites serve meals.




 Site No.

Type of Site1

Name of Each Site

Include only approved CACFP sites (per contract)
Tab from last field to
add additional rows

Total Enrollment
(At Risk Site)
Total Eligible Children (Emergency Shelter

No. Of Days
of Service

Average Daily Attendance

Breakfasts

AM Snacks

Lunches

PM Snacks

Suppers

Additional Snacks

Second Lunches

Second Suppers










































































































































































































































































































































































































































































































































































































































































































TOTALS

    




     

     

     

     

     

     

     

     

     

Transfer totals for each column to page 1 as indicated.

To
Line 1




To Line 4

To Line 5

To Line 5

To Line 5

To Line 5

To Line 5

To Line 5

To Line 5

To Line 5

(1) Enter type of site by code designation; AR = At Risk Afterschool Program ES = Emergency Shelter



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