FORM 1536-A
Instructions

APPLICATION AND MANAGEMENT PLAN
FOR DAY CARE HOME SPONSORS

06-2004

PURPOSE

To provide information required to determine if an applicant is eligible for participation in the Child and Adult Care Food Program (CACFP) Day Care Homes (DCH).

PROCEDURE

When to Prepare

Complete Form 1536-A to apply for participation in the CACFP DCH. In addition, use pages 8-11 whenever you have changes to your approved budget.

Number of Copies

Complete Form 1536-A and make two copies. The original and one copy must have original signatures.

Transmittal

Send both forms with original signatures to your Area Program Office. Keep one copy for your files.

How to Obtain Copies

Make additional copies as needed.

Form Retention

Keep Form 1536-A for three years and 90 days from the end of the contract period. Exception: If audit findings, claims, or litigation have not been resolved by the end of the retention period, all forms and records must be retained until all issues are resolved.

Terms and Definitions

Review the following terms and definitions to assist you in completing Form 1536-A appropriately. (Refer to the Terms and Definitions section of the Child and Day Care Food Program - Day Care Homes Handbook for additional information.)

Administrative Costs —  Allowable costs incurred by a contractor related to planning, organizing, and managing CACFP operations.

Business Related Offense —  A business related offense includes fraud, antitrust violations, embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, receiving stolen property, making false claims, obstruction of justice, or any other activity indicating a lack of business integrity.

Contractor —  A sponsoring organization that enters into an agreement with HHSC to assume final administrative and financial responsibility for CACFP operations.

Disqualified —  The status of a contractor, a responsible principal or responsible individual, or a day care home that is ineligible for participation in the CACFP.

Facility —  A sponsored day care home.

Income to the Program —  Any funds used in a contractor's food service except CACFP payments. Examples include, but are not limited to, funds from other government sources, children's payments for meals and food service fees, income from food sales to adults, cash donations, and grants from organizations or individuals.

Institution —  See "contractor."

Internal Controls —  The policies, procedures, and organizational structure of a contractor designed to reasonably assure that: (a) the CACFP achieves its intended result; (b) CACFP resources are used in a manner that protects against fraud, abuse, and mismanagement and in accordance with law, regulations, and guidance; and (c) timely and reliable CACFP information is obtained, maintained, reported, and used for decision-making.

National Disqualified List —  The list, maintained by the United States Department of Agriculture, of contractors, responsible principals and responsible individuals, and day care homes disqualified from participation in the CACFP.

Nonprofit Food Service —  All food service operations conducted by the contractor principally for the benefit of enrolled individuals from which all CACFP reimbursement funds and funds specifically restricted for food service are used solely for the operations or improvement of the food service.

Operating costs —  Expenses incurred by a contractor in serving meals to individuals under the CACFP.

Principal —  Any individual who holds a management position within, or is an officer of, a contractor or a sponsored facility, including all members of the organization's board of directors or the sponsored facility's board of directors.

Publicly Funded Program —  Any program or grant funded by public funds, including, but not limited to, federal, state, or local government funds.

Responsible Principal or Responsible Individual —  (a) A principal, whether compensated or uncompensated, whom SNP determines to be responsible for a contractor's serious deficiency; (b) any individual employed by, or under contract with, a contractor, whom SNP determines to be responsible for a contractor's serious deficiency; or (c) an uncompensated individual whom SNP determines to be responsible for a contractor's serious deficiency.

Seriously Deficient —  The status of a contractor or a day care home that has been determined to be noncompliant in one or more aspects of its operation of the CACFP.

DETAILED INSTRUCTIONS

Section I. CONTRACTOR INFORMATION

1. Complete the following contractor information.

Name of Contracting Agency —  Enter the legal name of the contracting organization that has tax-exempt status with the Internal Revenue Service (IRS) or is a public entity and has the ultimate legal responsibility for the agreement with the Texas Health and Human Services Commission (HHSC).

Texas ID Number —  Enter the 14-digit Texas identification number as issued by the comptroller of public accounts. If the request for a number is still pending, leave blank.

Contract No. —  Enter the seven-digit contractor number assigned by HHSC that begins with the pre-printed numerals "75." This is not the same number as the Program/TX number.

Program No. —  Enter the contracting organization's seven-digit TX number. New contractors should leave this space blank.

Mailing Address —  Enter the mailing address of the contracting organization, including street, city, state, and ZIP code. This address and ZIP code will be listed with the comptroller of public accounts.

Street Address —  Enter the street address, if different from the mailing address. This is the physical location of your primary business office where essential program functions are conducted and essential program records are maintained.

HHSC Region No. —  Enter the HHSC region number where your primary business office is located.

Contact Person —  Enter the name of the person HHSC should contact concerning this contract.

E-Mail Address —  If the organization contact person has an e-mail address, enter the e-mail address.

FAX No. —  If your organization has a fax machine, enter the number, including the area code.

Telephone No. —  Enter the telephone number, including area code, of the contact person.

Type of Contractor

2.—7. —  Self-explanatory.

8. Cash vs. commodities ... —  Indicate your preference for cash-in-lieu or commodities.

9. Projected number of providers ... —  Enter the number of providers you plan to sponsor this program year and on which you have based your estimated CACFP expenditures. You should have some justification on which to base the projected number of homes.

10. Number of providers ... —  Enter the number of Tier I and Tier II day care homes that you have submitted for approval to date.

11. Prior participation ... —  Indicate if your organization participated in the CACFP-DCH before October 1, 2003. If "Yes," give the dates of participation, and go on to Item B. If "No," go to Item C.

Indicate if you experienced a break in service. If "Yes," give the dates and complete Item C. If "No," go to Item 12. A sponsoring organization that has not previously participated in CACFP or who participated before October 1, 2003, but experienced a break in service may not sponsor a day care home that participated in the CACFP at any time during the 12 months before the date this application was submitted to HHSC. You must certify whether or not the day care homes that you submitted for participation have not participated in the CACFP at any time during the 12 months before the date you submitted this application to HHSC.

12. Number of children... —  Enter the number of children who are enrolled for child care in Tier I and Tier II day care homes that you have submitted for approval to date.

13. Number of children... —  Enter the number of income-eligible children who are enrolled for child care in Tier II day care homes that you have submitted for approval to date.

14. The contracting organization. . . . —  Assurance by the contracting organization.

SECTION II. MANAGEMENT PLAN

1. The contracting organization. . . . —  Assurance by the contracting organization.

2. Advance payments —  Indicate your preference to receive advance payments. If you indicate that you wish to receive advance payments, choose the type(s).

3. Disbursement of advance payments —  If you receive advance payments for meals, indicate how you will disburse them to providers within five working days of receipt from HHSC.

4. Disbursement of CACFP reimbursement —  Indicate how you will disburse CACFP reimbursement to providers within five working days of receipt from HHSC.

5. Reimbursement method —  Select the method you will use to reimburse providers. The choice you make may not be changed during the program year.

6. Staffing qualifications, A and B —  Complete the chart by describing the qualifications you require for the person(s) that performs required CACFP functions: you must have written policies and procedures that assign CACFP responsibilities and duties and ensure compliance with civil rights requirements.

7. Meal Service Record —  Indicate whether or not you will use Form 1539, Day Home Meal Service Record. If you will be using an alternate Form 1539 you must follow the procedures in your CACFP-DCH Handbook to obtain approval.

8. Infant Meals —  Indicate whether or not you will use Form 1530-A, Daily Meal Record for Infant Meals. If you will be using an alternate Form 1530-A, you must follow the procedures in your CACFP-DCH Handbook to obtain approval.

9. – 11. —  Self-explanatory.

12. Staffing for Monitoring —  You must demonstrate that you have an adequate number of staff to conduct required monitoring. Indicate if you sponsor 50 or more day care homes. If "Yes," you must complete the attached "Sponsoring Organization Monitoring Staff Information" form to verify that you have the required number of staff in terms of Full-Time Equivalents (FTEs) for the number of day care homes sponsored.

13. – 15. —  Self-explanatory.

16. Responsible Principals —  All contracting organizations must provide identifying information for the persons responsible for the overall operation of the CACFP. Provide the name, mailing address, and date of birth for the executive director, chairman of the board, and any other person who is responsible for the overall management of the CACFP.

17. Counties you are willing to serve ... —  Indicate the counties you are willing to serve.

18. Recruitment methods —  Indicate the recruitment method used for obtaining new day care home providers.

19. – 24. —  Self-explanatory.

25. Serious deficiency process —  Day care home providers who are seriously deficient in their operation of the CACFP must be placed in the "Serious Deficiency Process." See the CACFP-DCH Handbook for specific information on the serious deficiency process.

26. Not sponsoring excluded providers —  Describe your process for ensuring that you do not sponsor providers that have been excluded from participation in the CACFP. Your description must include reviewing the National Disqualified List and the List of Excluded Providers each time that you sign up a new day care home.

27. Other activities during normal business hours —  You must be available to your providers and HHSC staff during normal business hours.

SECTION III. PUBLIC RELEASE FOR FREE AND REDUCED PRICE MEALS

Self-explanatory.

SECTION IV. ADDITIONAL ATTACHMENTS REQUIRED

Self-explanatory.

SECTION V. BUDGET

Nonprofit Food Service Administrative Labor – Budget Justification Chart

Position and CACFP Duties —  Enter the titles of the positions. These should match your organizational chart. Enter a brief description of the CACFP duties performed.

1. Number of Personnel in this Position —  Enter the number of staff per position, such as "Director 1, Monitor 12, Clerical Support 2."

2. Annual Base Salary —  Enter the annual base salary for all staff in the designated position.

3. Additional Labor Costs and Benefits —  Enter the name of the benefit, such as FICA, health insurance, retirement, and the detailed computations justifying the amounts budgeted.

4. Total Base Salary and Benefits —  Add items 2 and 3 to arrive at this total.

5. Number of Hours Worked Per Month —  Enter the total number of hours worked per month.

6. Total Salary and Benefits Paid from the Nonprofit Food Service Account  —  Enter the total paid from the nonprofit food service account monthly.

7. Total Salary and Benefits Paid from the Nonprofit Food Service Account Annually —  Enter the total paid from the nonprofit food service account annually.

TOTAL ADMINISTRATIVE LABOR COSTS —  Enter the total for all costs in columns 6 and 7.

Use time distribution reports as the basis for estimating the labor hours for staff who do not work in the food service 100% of the time. When labor is claimed each month, it must be actual and not an estimate.

Costs of Operating a Nonprofit Food Service

Complete the chart based on the expenses paid from food service funds. You must specifically identify each item and explain how each cost was calculated. Transfer the total for each line item to page 11, 9A, Summary Estimated Annual Nonprofit Food Service Costs.

Note: HHSC determines the allowability of expenditures based on appropriate state and federal regulations and guidelines outlined in the CACFP-DCH Handbook.

Page 11 — DETAILED INSTRUCTIONS

Name of Contracting Agency —  Enter the legal name of the contracting organization.

Contract No. —  Enter the seven-digit contractor number assigned by HHSC that begins with the pre-printed numerals "75." This is not the same number as the Program/TX number.

Program No. —  Enter the contracting organization's seven-digit TX number. New contractors should leave this space blank.

Food Service Budget

Enter for each of the cost categories the amount budgeted for the food service from the respective budget justification pages.

9A. Summary Estimated Annual Nonprofit Food Service Costs

The food service budget is composed of the amounts for the cost categories listed below:

  1. Labor Costs – Salaries, Wages, Taxes, and Benefits
  2. Facilities and Space
  3. Supplies and Equipment
  4. Purchased Services
  5. Financial Costs
  6. Media Costs
  7. Organization Costs
  8. Other Costs

The amounts listed for the cost categories cannot be considered unless the respective amounts are justified and explained on the budget justification pages. Use as many pages as necessary.

9B. Other Income

  1. Enter the total annual costs of nonprofit food service from the budget above.
  2. Enter your projected annual CACFP administrative reimbursement for the program year (PY).
  3. Enter the total of other income to the nonprofit food service account, such as donations specifically designated for food service.
  4. Enter the total of lines 2 and 3. This amount must be equivalent to the amount in line 1.

9C. Certification

An authorized official of the contracting organization must sign and date the form. This must be someone authorized on Form 4508, Certificate of Authority. Enter the name and title of the official in the spaces provided.