CHILD AND ADULT CARE FOOD PROGRAM

							                    CHILD AND ADULT CARE FOOD PROGRAM
                 FAMILY DAY CARE SPONSOR POLICY STATEMENT


Agreement Number:____________________

Institution Name:________________________________________________

Address:_________________________________________________________

City and State:__________________________________________________


                      POLICY STATEMENT FOR FREE MEALS
                     SPONSORS OF FAMILY DAY CARE HOMES



The ___________________________________________ assures the Department of
                     (Name of Sponsor)
Education, Office of Hawaii Child Nutrition Programs that:

1. Current income eligibility documentation, including income verification information,
   will be maintained on file for all providers qualified for Tier I reimbursement rates on
   the basis of household income.

2. Current income eligibility documentation will be maintained on file for all providers’
   own children claimed for meals, for those providers qualified for Tier I
   reimbursement rates based on area eligibility.

3. Current income eligibility documentation will be maintained for all children enrolled in
   Tier II homes whose meals are being reimbursed at Tier I rates.

4. The Point of Service (POS) meal counts are defined when the child(ren) is/are at the
   table seated during the meal service. Meal counts are taken at this time.

5. All children enrolled at the homes described on the application forms partake of the
   same meals at no separate charge regardless of race, color, national origin, age,
   sex or disability. There is no discrimination in admissions policy, meal service, or the
   use of facilities. To file a complaint of discrimination, write USDA, Director, Office of
   Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or
   call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have
   speech disabilities may contact USDA through the Federal Relay Service at (800)
   877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider
   and employer.”




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6. All meals served to enrolled children are reported on the reimbursement claim form
   in accordance with the method prescribed by the Department of Education, Office of
   Hawaii Child Nutrition Programs.

7. There will be no identification of Tier I and Tier II recipients in day care homes,
   income eligibility information concerning individual households will not be shared
   with day care home providers, and access to eligibility information will be restricted
   to those persons directly connected with the administration and enforcement of the
   Program.

******************************************************************************************

FOR SPONSOR:                                                 FOR DOE OHCNP ONLY:



Name (Print)________________________                 Name (Print)______________________



Signature                                           Signature_________________________

Title_______________________________                Title_____________________________

Date__________________________                      Date_____________________________


COMPLETE BOTH COPIES OF THE POLICY STATEMENT, SIGN AND DATE BOTH
COPIES IN BLUE INK, AND RETURN BOTH COPIES WITH YOUR APPLICATION
PACKAGE.




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Revised 7/09




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