Wisconsin Department of Public Instruction

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Wisconsin Department of Public Instruction



PI-1425 (Rev. 07-15)

INSTRUCTIONS: Complete requested information and permanently maintain on file in sponsor’s office.

Provider (CARES) Number

Sponsor Assigned Provider Number


Sponsoring Organization

Sponsoring Organization’s Address Street, City, State, Zip

Provider’s Name

Provider’s Street Address Street, City, State, Zip

Provider Birth Date (a) Mo./Day/Yr.

Provider Email Address

This Agreement, entered into this _____ day of ___________________________, 20____ by and between the above-named Sponsoring Agency and the Provider is permanent unless amended by the Wisconsin Department of Public Instruction (DPI) or terminated by either party. It specifies the rights and responsibilities of the Sponsoring Organization and the Provider as participants in the United States Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP), administered by the DPI. Program payments to both the Sponsoring Organization and the Provider are conditional contingent upon the availability of federal funds.

Rights and Responsibilities of the Day Care Home—In accordance with Child and Adult Care Food Program regulations, the day care home agrees to:

  1. Prepare and serve meals at no charge which meet the meal pattern requirements for the ages of children being served as specified in program regulations.

  2. Maintain on a daily basis accurate records of attendance, menus, and the number of meals by type and child name (or designation) that are served to enrolled children. (Menus and the number of meals served by type and child name (or designation) must be recorded by the end of each operating day.)

  3. Claim meals for reimbursement which have been approved and only served to children enrolled for and receiving child care services. Payment may be made for meals served to the provider’s own child (children) 12 years of age and under if the household properly documents its receipt of Food Stamps, W-2 Cash Benefits, or FDPIR, or if the household’s income meets the guidelines established for the free or reduced categories. In addition to being income eligible and enrolled, meals served to the provider’s own children are reimbursable only when one or more nonresident enrolled children are present and participating in the same meal(s). Meals claimed, including provider’s own, can not be in excess of the day care home’s authorized capacity.

  4. Maintain accurate enrollment information and promptly submit CACFP child enrollment forms for any new child(ren) in care. Promptly notify Sponsoring Organization when a child(ren) is no longer in care. Submit additional program documentation (for example, sponsor-created infant formula/feeding agreement, special diet form, verification of special needs, etc.) as required by the Sponsor.

  5. Provide documentation that Provider’s home is currently licensed as a family day care center, registered or certified as a family day care home, or approved in accordance with local day care regulations, and promptly inform the Sponsoring Organization of any change in the home’s license or certification approval status.

  6. Complete annual training session(s) as required by the Sponsoring Organization. Failure to meet the annual training requirement by September 30 will result in corrective actions by the sponsoring organization which may include a declaration of serious deficiency.

  7. Allow representatives from the Sponsoring Organization, USDA, DPI and other State and Federal officials to make announced and unannounced visits to the Provider’s home to review the meal service and Program records during the home’s official hours of business as a child care facility.

  8. Serve meals to enrolled children without regard to protected classes. (This applies only during the home’s official hours of business as a child care facility). All children enrolled for child care must also be enrolled in the CACFP, and if the child is less than 12 months of age a completed infant formula/feeding agreement (or equivalent documentation as specified by the Sponsoring Organization) must be submitted to the Sponsoring Organization.

  9. Make meal count and menu records available to the Sponsoring Organization by the _________ day of each month.

  10. Allow the Sponsoring Organization, the DPI and the USDA to conduct household contacts.

  11. Provide the parents or guardians of enrolled children with information that describes the CACFP and its benefits (Building for the Future flier).

  12. Notify the Sponsoring Organization in advance whenever the provider is planning to be out of their home with the children during the approved meal service periods. If the Provider fails to notify the sponsor and an unannounced review (home visit) is conducted when children are not present in the day care home, a claim(s) for meals that would have been served during the unannounced review (home visit) must be disallowed for CACFP reimbursement by the Sponsoring Organization.

  13. Assume full and final administrative and financial responsibility for the operation of the CACFP in the day care home.


WE HEREBY CERTIFY that the information on this form is true and correct to the best of our knowledge, and that we will comply with the rights and responsibilities outlined in this Agreement. The Provider also certifies that he/she is not participating in the Child and Adult Care Food Program under any other Sponsoring Organization. We understand that state agency and USDA officials may, for cause, verify information. We also understand that this information is being given in connection with the receipt of federal funds, and that deliberate misrepresentation may subject us to prosecution under applicable state and federal criminal statutes.

Signature of Authorized Representative of Sponsoring Organization

Date Signed Mo./Day/Yr.

Signature of Provider

Date Signed Mo./Day/Yr.

AGREEMENT (cont’d.)

Rights and Responsibilities of the Sponsoring Organization

In accordance with Child and Adult Care Food Program regulations, the Sponsoring Organization agrees to:

  1. Enter into an agreement only with a day care provider who is currently licensed, certified, registered or approved in accordance with Part 226.6(d) of the CACFP regulations.

  2. Train the Provider in program requirements before the Provider begins participation in the CACFP.

  3. Offer additional training opportunities not less frequently than annually.

  4. Respond to a Provider’s request for technical assistance.

  5. Provide all CACFP recordkeeping forms to the Provider.

  6. Not charge a fee to the Provider for CACFP administrative services.

  7. Disburse to the Provider the full amount of CACFP payments received by the Sponsoring Organization from the DPI within five days of receipt in accordance with CACFP regulations [7CFR 226.16(8)].

  8. Assure that all meals claimed for reimbursement are served to enrolled children under the age of 13 years, except that for children of migrant workers the age limit is 15 years and under, and for disabled children (as defined by the state and enrolled in a home serving a majority of persons 18 years of age and under) there is no limit, without regard to race, sex, disability, color, age or national origin, and that all meals claimed meet the USDA meal require­ments.

  9. Maintain current enrollment records for all enrolled children. Enrollment records must be updated annually to reflect each child’s current address and phone number.

  10. Assure claim for payment is not made for meals served to children attending in excess of the authorized capacity as determined by applicable licensure, certification or approval regulations.

  11. Assure claim for payment is made for no more than two meals and one snack or two snacks and one meal per child per day according to current USDA regulations.

  12. Review CACFP operations at each home a minimum of three times each year during normal hours of child care operations. At least two of the three reviews (home visits) must be unannounced. One of the unannounced reviews (home visits) must be conducted at a Pro­gram meal service with children present. Monitors conducting unannounced reviews (home visits) must provide photo identifica­tion that demonstrates that they are employees of the sponsoring organization. In addition, if in a review of a facility a sponsoring organization detects one or more serious deficiencies, the next review of that facility must be unannounced. Serious deficiencies for day care homes are those set forth in section V of the Application/ Agreement, PI-1459.

  13. Disallow for reimbursement meals served prior to the day of the onsite review (home visit) by the sponsoring organization when menus and/or the number of meals served by type and child name (or designation) have not been recorded as of the day of the onsite review (home visit).

  14. Inform tier II day care homes of all the options for receiving reimbursement for meals served to enrolled children.

  15. Collect, upon the request of a tier II day care home, applications and determine the eligibility of enrolled children for free or reduced meals.

  16. Conduct household contacts of enrolled children as required by CACFP regulations and USDA and DPI guidance.

  17. Provide each home with information that describes the CACFP and its benefits (parental notification flier) and ensure that all parents and guardians of children enrolled in the day care home are given this information.

Transfer Policy

A transfer is defined as a Provider shifting their Program participation from one sponsoring organization to another sponsoring organization without any lapse in Program eligibility. A Provider wishing to transfer must be in good standing with his/her current sponsor and comply with the requirement to give at least 15 days’ written notice prior to termination of his/her agreement with the current sponsor. A home application (PI-1472) must be completed and the data submitted electronically to DPI prior to the date of transfer. In addition, a valid certificate/license and the completed transfer form [PI-6076 (Rev. 04-07) Day Care Home Sponsor Transfer Request] must be received in the DPI office, from the new sponsor, on or before the date of transfer. A day care home provider is limited to one transfer per year except under extenuating circumstances, such as termination of the sponsoring organization’s agreement or other circumstances defined by the state agency. A Provider who is within the first year of initial participation in the CACFP may transfer on the first day of any given month. The effective date of the transfer shall be the first month following the successful achievement of the above requirements. After the first year of initial CACFP participation a transfer may only occur on the first day of the month following the Provider’s anniversary date of initially joining the CACFP.


The Sponsoring Organization or the Provider may terminate this Agreement upon ten (10) days written notice for cause or, subject to stipulations by the Wisconsin Department of Public Instruction, for convenience [7CFR 226.18(b)(8)]. A provider in good standing may terminate their Program agreement for convenience, with ten (10) days written notice, but forfeits the right to Program participation with another Sponsoring Organization for a minimum of one full calendar month.

Administrative Review

If requested, a family day care home shall be provided an appeal prior to any determination to terminate participation for cause of the family day care home under the CACFP or if the Sponsoring Organization suspends participation due to health and safety concerns. The determination by the Sponsors Forum Appeals Review Committee or its designee shall be the final administrative determination to be afforded to the family day care home provider.

The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department.  (Not all prohibited bases will apply to all programs and/or employment activities.)

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov.

Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).  

USDA is an equal opportunity provider and employer.

(a) Information must be supplied by applicant. Failure to supply this information will result in the lapse of Program eligibility.

White—Sponsor Retain on File Canary—Provider Retain on file

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