Office Rent/Use Allowance Rent/Lease Use Allowance or Depreciation (circle one) Insurance (cover loss of Federal property) Maintenance Janitorial Sub-total Utilities Gas/Electric Water/Sewer Trash Removal Other (specify) Sub-total Annual Indirect Costs (submit Cost Allocation Plan) Include all expenses attributable to SFSP operations, regardless of whether SFSP reimbursement will be sufficient to cover them. Please consult the Operating and Administrative Cost Sheet included with your application packet to help determine whether expenses are administrative or operational. Administrative Costs Proposed DHSS Use Only Operational Costs Proposed Administrative Approved Operational Budget Budget Administrative Budget Salaries/Fringe $ Food Service $ Labor/Fringe Benefits & Monitoring Staff Rent for Office Space $ Food $ Office Supplies $ Supplies $ Administrative $ Transportation of Food $ Mileage Audit Fees $ Utilities $ Telephone $ Equipment Rent $ Postage $ Other (specify below) Printing/Copying $ $ Advertising $ $ Other (specify) $ $ Total Administrative $ Total Operational Costs $ Costs Grand Total Administrative Meals $ Operational Meals X Rate $ X Rate CERTIFICATION Signature by the superintendent/board president/director and/or authorized representative below certifies that: The information on this form is true and correct to the best of my knowledge. Yes No I understand that this information is being given in connection with the receipt of federal funds, and that deliberate Yes No misrepresentation may subject me to prosecution under applicable state and federal criminal statutes. The program must be made available to all children regardless of race, color, national origin, sex, age, or disability. Yes No (Not all prohibited bases apply to all programs) The program is directly operated by the applicant organization (sponsor) at all sites. Yes No Reimbursement will be claimed only for meals served to eligible children. Yes No Each site will maintain a daily point-of-service meal count for each meal or snack service, which will be collected at Yes No least weekly by the sponsor. The superintendent/board president/director and/or authorized representatives accept final administrative and financial Yes No responsibility for all SFSP operations at the applicant organization’s (sponsor’s) sites(s).
Office Rent/Use Allowance Rent/Lease Use Allowance or Depreciation (circle one) Insurance (cover loss of Federal property) Maintenance Janitorial Sub-total Utilities Gas/Electric Water/Sewer Trash Removal Other (specify) Sub-total Annual Indirect Costs (submit Cost Allocation Plan) Include all expenses attributable to SFSP operations, regardless of whether SFSP reimbursement will be sufficient to cover them. Please consult the Operating and Administrative Cost Sheet included with your application packet to help determine whether expenses are administrative or operational. Administrative Costs Proposed Administrative Budget DHSS Use Only Approved Administrative Budget Operational Costs Proposed Operational Budget Salaries/Fringe $ Food Service Labor/Fringe Benefits & Monitoring Staff $ Rent for Office Space $ Food $ Office Supplies $ Supplies $ Administrative Mileage $ Transportation of Food $ Audit Fees $ Utilities $ Telephone $ Equipment Rent $ Postage $ Other (specify below) Printing/Copying $ $ Advertising $ $ Other (specify) $ $ Total Administrative Costs $ Total Operational Costs $ Grand Total Administrative Meals X Rate $ Operational Meals X Rate $ CERTIFICATION Signature by the superintendent/board president/director and/or authorized representative below certifies that: Yes No The information on this form is true and correct to the best of my knowledge. Yes No I understand that this information is being given in connection with the receipt of federal funds, and that deliberate misrepresentation may subject me to prosecution under applicable state and federal criminal statutes. Yes No The program must be made available to all children regardless of race, color, national origin, sex, age, or disability. (Not all prohibited bases apply to all programs) Yes No The program is directly operated by the applicant organization (sponsor) at all sites. Yes No Reimbursement will be claimed only for meals served to eligible children. Yes No Each site will maintain a daily point-of-service meal count for each meal or snack service, which will be collected at least weekly by the sponsor. Yes No The superintendent/board president/director and/or authorized representatives accept final administrative and financial responsibility for all SFSP operations at the applicant organization’s (sponsor’s) sites(s).