FORM 1536-D
Instructions

RENEWAL APPLICATION AND MANAGEMENT PLAN
FOR DAY CARE HOME SPONSORS

07-2003

PURPOSE

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

PROCEDURE

When to Prepare

Complete Form 1536-D to renew your application for participation in the CACFP-DCH. In addition, complete pages 4-7 whenever you have changes to your approved budget.

Number of Copies

Complete Form 1536-D 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-D 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-D 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 DHS 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 all 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 Department of Human Services (DHS).

Texas ID No. —  Enter the 14-digit Texas identification number as issued by the comptroller of public accounts.

Contract No. —  Enter the seven-digit contractor number assigned by DHS 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.

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.

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

Contact Person —  Enter the name of the person DHS 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.

2. — 4. —  Self-explanatory.

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

6. 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.

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

8. 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.

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

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

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

12. —  Self-explanatory.

13. Staffing Qualifications —  A and B. Complete the chart by describing the qualifications you require for the person(s) that perform required CACFP functions. You must have written policies and procedures that assign CACFP responsibilities and duties and ensure compliance with Civil Rights requirements.

14. 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.

15. 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.

16. — 17. —  Self-explanatory.

18. You must submit the following attachments. —  Mark the "Yes" box to indicate that you have attached the required information or mark the "N/A" box to indicate that the requirement does not apply to your organization.

Section II. BUDGET

1. Disclosure —  Self-explanatory.

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.

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

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

Column 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.

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

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

Column 6 — Total Salary and Benefits Paid . . . — Enter the total paid from the nonprofit food service account monthly.

Column 7 — Total Salary and Benefits . . . — Enter the total paid from the nonprofit food service account annually.

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

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

2. – 8. —  Complete the chart based on the expenses paid from the nonprofit food service account. You must specifically identify each item and explain how each cost was calculated. Transfer the total for each line item to page 7, 9A, Estimated Food Service Costs.

PAGE 7 – DETAILED INSTRUCTIONS

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

Contract No. —  Enter the seven-digit contractor number assigned by DHS 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.

9A. Summary Estimated 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.

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

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

9B. Other Income

  1. Enter the total annual costs for 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.

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 this official in the spaces below the signature.

FOR DHS USE ONLY —  DHS will enter the effective date of the change.