Administration and Forms for CACFP

CACFP Forms

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Form Name Form Number Form Download Form Download (Alternative Format) Instructions Download Program Name
CACFP Meal Benefit Income Eligibility Form (Adult Care) in Spanish Download File Download File CACFP - Adult Day Care
CACFP Meal Benefit Income Eligibility Form (Child Care) Download File Download File CACFP - Child Care Center
CACFP Meal Benefit Income Eligibility Form (Child Care) Download File Download File CACFP - Day Care Home
CACFP Meal Benefit Income Eligibility Form (Child Care) in Spanish Download File Download File CACFP - Child Care Center
CACFP Meal Benefit Income Eligibility Form (Child Care) in Spanish Download File Download File CACFP - Day Care Home
CACFP Meal Benefit Income Eligibility Form Letter to Households - Tier II Day Care Homes Download File CACFP - Day Care Home
CACFP Meal Benefit Income Eligibility Form Letter to Households - Tier II Day Care Homes - in Spanish Download File CACFP - Day Care Home
CACFP Meal Benefit Income Eligibility Form Letter to Households (Adult Day Care) Download File CACFP - Adult Day Care
CACFP Meal Benefit Income Eligibility Form Letter to Households (Adult Day Care) in Spanish Download File CACFP - Adult Day Care
CACFP Meal Benefit Income Eligibility Form Letter to Households (Child Care Centers) Download File CACFP - Child Care Center
CACFP Meal Benefit Income Eligibility Form Letter to Households (Child Care Centers) in Spanish Download File CACFP - Child Care Center
CACFP Meal Benefit Income Eligibility Form Letter to Provider - Tier I or Provider's Own Children Download File CACFP - Day Care Home
CACFP Meal Benefit Income Eligibility Form Letter to Provider Tier I or Provider's Own Children in Spanish Download File CACFP - Day Care Home
CACFP Medical Statement Form Download File Download File CACFP - Adult Day Care
CACFP Medical Statement Form Download File Download File CACFP - At-Risk Afterschool
CACFP Medical Statement Form Download File Download File CACFP - Child Care Center
CACFP Medical Statement Form Download File Download File CACFP - Day Care Home
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts H2048 Download File Download File CACFP - Adult Day Care
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts H2048 Download File Download File CACFP - At-Risk Afterschool
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts H2048 Download File Download File CACFP - Child Care Center
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts H2048 Download File Download File CACFP - Day Care Home
Certification Regarding Federal Lobbying H2049 Download File Download File CACFP - Adult Day Care
Certification Regarding Federal Lobbying H2049 Download File Download File CACFP - At-Risk Afterschool
Certification Regarding Federal Lobbying H2049 Download File Download File CACFP - Child Care Center
Certification Regarding Federal Lobbying H2049 Download File Download File CACFP - Day Care Home
Child Care Food Program Collection Procedures H4515-A Download File Download File CACFP - Child Care Center
Child Nutrition Programs Waiver Request Download File Download File CACFP - Adult Day Care
Child Nutrition Programs Waiver Request Download File Download File CACFP - At-Risk Afterschool
Child Nutrition Programs Waiver Request Download File Download File CACFP - Child Care Center
Child Nutrition Programs Waiver Request Download File Download File CACFP - Day Care Home
Claim for Reimbursement Worksheet - Meals H4502 Download File Download File Download File CACFP - Adult Day Care
Claim for Reimbursement Worksheet - Meals H4502 Download File Download File Download File CACFP - At-Risk Afterschool
Claim for Reimbursement Worksheet - Meals H4502 Download File Download File Download File CACFP - Child Care Center
Contracting Entity Request for Waiver of 15% Limit for Allowable Administrative Costs Download File CACFP - Adult Day Care
Contracting Entity Request for Waiver of 15% Limit for Allowable Administrative Costs Download File CACFP - At-Risk Afterschool
Contracting Entity Request for Waiver of 15% Limit for Allowable Administrative Costs Download File CACFP - Child Care Center
Daily Meal Count and Attendance Record (At-Risk) H1535-AT Download File Download File CACFP - At-Risk Afterschool
Daily Meal Count and Attendance Record (At-Risk) H1535-AT Download File Download File CACFP - Child Care Center
Daily Meal Count and Attendance Record (Centers and Emergency Shelters) H1535 Download File Download File CACFP - Adult Day Care
Daily Meal Count and Attendance Record (Centers and Emergency Shelters) H1535 Download File Download File CACFP - Child Care Center
Daily Meal Count, Attendance, and Meal Production Record (H1539) H1539 Download File Download File CACFP - Day Care Home
Daily Meal Production Record - Adult Day Care H1654 Download File Download File CACFP - Adult Day Care
Daily Meal Production Record - Child Care H1530 Download File Download File CACFP - At-Risk Afterschool
Daily Meal Production Record - Child Care H1530 Download File Download File CACFP - Child Care Center
Daily Meal Production Record - Infants H1530-A Download File Download File CACFP - Child Care Center
Daily Meal Production Record - Infants H1530-A Download File Download File CACFP - Day Care Home
Direct Deposit Authorization 74-176 Download File CACFP - Adult Day Care
Direct Deposit Authorization 74-176 Download File CACFP - At-Risk Afterschool
Direct Deposit Authorization 74-176 Download File CACFP - Child Care Center
Direct Deposit Authorization 74-176 Download File CACFP - Day Care Home
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Assistance available in English and Spanish. Please call 877-TEX-MEAL (877-839-6325) for help. Additional translations services available as well.

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

1. Mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410; or
2. Fax: (833) 256-1665 or (202) 690-7442; or
This institution is an equal opportunity provider.
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