Severe Need Application Form 2008 09 by HC121104191537

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									                                                               ARKANSAS DEPARTMENT OF EDUCATION
                                                                     CHILD NUTRITION UNIT

                                                               SY 2008-2009 APPLICATION FORM
                                                 Severe Need Funding for School Breakfast Program
                                             Documentation of Eligibility for Severe Need Reimbursement

                                                         No._____________________________________ ounty_____________________________
District ___________________________________________ LEA LEA No. __________________________     C
                                                                                               County ______________________________
Preparer's Name__________________________________________________________                                                   Preparer's Phone No.__________________________
SEE ATTACHED INSTRUCTIONS. Contact Jimmy Burks at the ADE Child Nutrition Unit, 501-324-9502, if further assistance is needed.

                                                                    COMPLETE FOR ALL SCHOOLS
                                             TOTAL MEALS MUST AGREE WITH TOTAL MEALS CLAIMED FOR SY 2006-07


                                                                A: SY 2006 - 2007 DATA                                                                                 SY 08-09
                                                                                                                                                                        DATA        CNU
        1                                2                         3            4          5            6          7                                  8          9                 Office
     LIST IN           LIST ALL SCHOOLS IN DISTRICT                                Lunches Served in SY 2006-2007                                             Active                Use
   ASCENDING          School Name as Reported on Annual                                 Reduced       Total                                                  School for             Only/
                                                                                                                                                                                   Severe
  LEA NUMBER            School Reporting through APSCN           Grade        Free       Price      Free/Red.   Total All                Percentage Free and SY 08-09               Need
     ORDER              (Enrollment by School, Oct. 1, 2006)     Levels     Lunches     Lunches      Lunches    Lunches                  Red. Price Lunches Yes / No*               O.K.
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                                                                 (This form may be duplicated if additional space is needed.)

* If response in Col. 9 is "NO," please explain circumstances. For instance, if the district has closed, added or reorganized schools for SY 08-09,
indicate below the current location(s) of students eligible for severe need based on SY 06-07 data. (Attach additional pages, if necessary)




                                                   B: SY 2008-2009 SCHOOLS (NOT LISTED ABOVE)                                                                                       CNU
        1                                2                         3            4                5                 6                                 7                             Office
     LIST IN                                                                                                                                                                        Use
                                                                                                                                                                                    Only/
   ASCENDING
                                                                                                                                                                                   Severe
  LEA NUMBER          List Schools for SY 2008-2009              Grade                     Reopened/   Grades                                  Explanation                          Need
     ORDER              NOT on SY 2006-2007 List                 Levels       New           Closed   Reorganized                   (Attach additional pages, if necessary)          O.K.
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          I certify to the Arkansas Department of Education that the above information is true and correct, and that records are available to support the information.

Typed Name of Superintendent or Authorized Representative                           Telephone                            Date                   Original Signature Required




PLEASE RETURN TWO SIGNED ORIGINALS
BY MARCH 3, 2008 TO:
Arkansas Department of Education                                          Approved by:_________________________________________                            Date: __________________
Child Nutrition Unit                                                                  Director, Child Nutrition Unit
2020 West 3rd Street, Suite 404                                                       Arkansas Department of Education
                                                                                                                                                                  7CFR 220.9(e)
Little Rock, AR 72205
                                                                                                                                               ADE Form No. FIN-01-00-002 R/1-08

								
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