Institution Change Notification Form

Institution Change Notification Form
Child and Adult Care Food Program
Institution Name
Agreement Number
This form should be used to update any changes to the legal or governing body operating the CACFP. Only check the boxes that require an update to the application and enter the new information in the space provided. Note: Change of Ownerships require a new application. If terminating participation, complete the Voluntary Closure Form.
Change Type

Institution Name (Attach Certificate of Name Change)
Change Type

Federal Employer ID
Change Type

Ownership CodeGovernment Sole ProprietorshipLimited Liability CorporationOut of State CorporationState:Zip:Organization TypeProfitNonprofit
Change Type

Board Member Changes
New Information
Institution Name (Attach Certificate of Name Change)
Federal Employer ID
Street
City
State
Zip
Ownership Code

Physical/Street AddressCorporation Partnership
Tax Status

Board meeting minutes attached. Minutes dated, adopted and signed.Date of Board Meeting:
Nonprofit
Date of Board Meeting

MonthDayYear
Date
Board meeting minutes attached. Minutes dated, adopted and signed.

MonthDayYear
Date
Principal/Program Contact

Effective: *This person must attend
Effective: *This person must attend
CACFP Training within 90 days of the change. Contact Adm. Asst: (404) 657-1779
New Principal Title
New Principal Title
New Principal Title
FSMC Name
FSMC Name

Food service contract attached.
(FSMC)

Food Service Management Company
To change the bank account information, use the Vendor Management Form. Update the Accounting Tracking System section of the Management Plan in GA ATLAS if making a change to the procedures for maintaining CACFP income/expenses separately from other funds.

To add or remove users assigned by individual names, use the Electronic Enrollment/Change funds. Form. For organizations assigned user names by organizational acronym, contact the Application Specialist.

*If there is a change in legal ownership, including a change in legal entity although still operated by the same primary owners, contact the Application Specialist. Contact the Application Specialist as well if the Federal ID Number, Ownership Code or Organization Type has changed.
I certify that I am authorized to make this request to DECAL and that the information I have provided above is true and correct.

Clear
I certify that I am authorized to make this request to DECAL and that the information I have provided above is true and correct.
I certify that I am authorized to make this request to DECAL and that the information I have provided above is true and correct.

MonthDayYear
Date
Bright from the Start: Department of Early Care and Learning Attn: CACFP Application Specialist 2 Martin Luther King Jr. Drive, SE Suite 754, East Tower Atlanta, GA

Fax to:CACFP Assigned Application Specialist Fax #:(678) 717-6050-Paula Lawrence(Zero(0)-G) (770)342-3104-Shericka Blount(H-P) (770)342-3171-Kenya Taylor (Q-Z)

FOR DECAL USE ONLY: SAVE Affidavit required: Y N GA DL Verification: Y

CACFP Institution Change Notification Form-Revised DECAL Official:
Date

MonthDayYear
Date
Should be Empty:

Institution Change Notification Form

Child and Adult Care Food Program

New Information