Get documents about "Excess Funds Claim Form
Description
Excess Funds Claim Form document sample
Document Sample
REIMBURSEMENT CLAIM
FOR FRESH FRUIT AND VEGETABLE PROGRAM
INSTRUCTIONS: Submit monthly claims to the Office of Child Nutrition (OCN) no later than the monthly deadlines
in the fruit and vegetable program claim instructions (7th of the month). Retain a copy for your records. All receipts,
invoices and other evidence of purchase must be retained and available for further review or audit for a period of 3 years
after the date of final claim submission for the fiscal year to which they pertain.
SCHOOL INFORMATION
Name of School:
School Address:
Name of District:
Name of Contact:
Contact Phone Number: Contact E-mail Address:
CLAIM INFORMATION
Grant Period: July 1, 2010 to June 30, 2011 Award Amount:
Claim Month/Year Original Claim
Number of Operating Days in the Report Month: Revised Claim
Fresh Fruit and Vegetable Program Expenses [Please itemize expenses on the charts below]:
Operating Costs: Monthly Claim
Fresh Fruits and Vegetables $0.00
Fuel Surcharge $0.00
Direct Labor $0.00
Small Supplies/Other $0.00
Total Operating Costs $0.00
Administrative Costs:
Labor $0.00
Equipment $0.00
Other $0.00
Total Administrative Costs $0.00
Total per Year Limited to 10% of Grant Award
Total Claim Costs $0.00
SIGNATURE (Required)
We certify that to the best of our knowledge, this claim is true and correct in all respects, that records are available to support this
claim, and that it is in accordance with the terms of the existing Agreements; and that payment has not been received. We recognize
that we will be fully responsible for any excess funds received due to erroneous or neglectful reporting herein. We also understand
that this information is being given in connection with the receipt of Federal Funds; and that deliberate misrepresentation may subject
us to prosecution under applicable State and Federal criminal statutes. We have read the instructions for filing the claim and are
aware that if it is not submitted by the claim deadline the claim may not be paid.
Date
Authorized Ofiicial (signature):____________________________________________________________________
(please print name)________________________________________
Page 1 2010-11 FFVP Claim Form
Fresh Fruit and Vegetable Costs
Operating Costs:
Size/Weight of
Product Description Shipping Unit Number of Units Cost Per Unit Total Cost
Fresh Fruits
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Total Fresh Fruit Costs: $0.00
Operating Costs: Size/Weight of
Product Description Shipping Unit Number of Units Cost Per Unit Total Cost
Fresh Vegetables
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Total Fresh Vegetable Costs $0.00
Total Fresh Fruit And Vegetable Costs $0.00
Page 2 2010-11 FFVP Claim Form
Operating Costs Continued:
Total Cost
Fuel Surcharge Include date of charge
$0.00
$0.00
$0.00
$0.00
$0.00
Fuel Surcharge $0.00
Direct Labor Costs: (Labor directly related to the preparing or serving of fresh fruits and vegetables) Attach copy
of time sheets showing hours dedicated to Fresh Fruit & Vegetable Program
Employee Hours Wage Fringe Total Cost
$0.00
$0.00
$0.00
$0.00
Total Direct Labor Costs $0.00
--Small Supplies/Other: (Small supplies – e.g. napkins, paper plates, utensils, bowls, pans and the like, Other –
includes such items as LOW or NO-FAT dips etc.) Total Cost
Total Supply Costs $0.00
Total Operating Costs $0.00
Administrative Costs (Include equipment, leasing and labor costs not related to preparing and serving of fruits and
vegetables; labor includes but is not limited to planning, ordering, writing menus, reporting, billing, tracking, inventory, etc.
Total administrative costs are limited to 10% of the grant award. Total Costs
Administrative Labor If submitting CN Director Salary, must have submitted written proof of salary proration.
Total Administrative Labor $0.00
Equipment
Total Equipment $0.00
Other
$0.00
Total Administrative Costs $0.00
Total Claim Costs $0.00
Page 3 2010-11 FFVP Claim Form
