CACFP Change Notification Form by HC12071419917


									                               Site Change Notification Form for Independent Centers
                                        Child and Adult Care Food Program
Institution Name                                                                       Agreement Number
Site Name & Address:
Place a check only in the boxes that require an update to the application and enter the new information in the
space provided. You may be required to submit supporting documentation for the change. Items not listed on
this form do not need to be updated in the application until a renewal application is submitted.

           Change Type                                                                  New Information

     Site Address

     Site Name

     Site Contact Name
                                            Phone Number: (            )                       Extension:
     Contact Information
                                            Fax Number: (          )                           Email address:
     Licensed Capacity (Attach              Capacity @ 35 Sq. Feet:                                       Capacity @ 25 sq. feet:
 supporting doc. from licensing division)
                                            Program types can only be changed by submitting a new site application. To add the At
 Program Type
                                            Risk After School Care Program, use the At Risk After School Care Program Application
 Operating Months, Hours,                                                                                                           Claim Month
           Days                                                                                                                       Effective
                                               Jan        Feb              Mar              April            May       June
     Months of Operation
                                               July       Aug              Sept             Oct              Nov       Dec
     Hours of Operation                     Center will open at:                  Center will close at:

     Days of Operation                        Mon       Tues           Wed         Thurs            Fri       Sat     Sun
      Meal Type Change                                                     Meal Times        Claim Month
      (Circle Add or Delete)                                                                    Effective
    At Risk Meal and/or Snacks: Use the At Risk After School Care Program Application to add this meal type.
     Breakfast        Add/ Delete           Begin:             End:
     Lunch            Add/ Delete           Begin:             End:

     AM Snack Add/ Delete                   Begin:             End:

     PM Snack Add/ Delete                   Begin:             End:

     Supper           Add/ Delete           Begin:             End:

 I certify that I am authorized to make this request to DECAL and that the information I have provided above
 is true and correct.
        _________________________              ________________________          __________________
                         Signature                                                  Title                                           Date

Mail to: Bright from the Start: Department of Early Care and Learning                               Fax to: CACFP Application Specialist
CACFP Application Specialist                                                                                FAX #: (770) 342-3104
2 Martin Luther King Jr. Drive, SE
Suite 670, East Tower
Atlanta, GA 30334

Revised 8/11

To top