Purpose: State Agencies are required to validate day care staff at new center/home facilities requesting participation and approval in the CACFP according to 7 CFR Part 226.6(k)(3)(xii): Presence on the National disqualified list.
Instructions: When adding new homes or centers for CACFP participation under sponsors' agreements, CACFP sponsors are to complete, in the sections applicable, the names, addresses, and birth dates of executive directors, owners, employees of the facility. This completed form is to accompany the required documents for new sites: licenses (homes and centers); 501(c)(3) (Non-Profit Centers); alphabetized list of enrolled children, CCIS Provider Payment Summary or Free/Reduced Meal Benefit Forms (For-Profit centers).
Please complete the applicable section:
SPONSOR: CBS State Sponsored Food Program 85 Tomlinson Rd. Suite F, Huntingdon Valley Pa 19006
AGREEMENT # 300-51-000-7
Please Note: Addresses entered below should be Owner's HOME Address. (Not the Center's address)