Milk Donation Form

This form must be submitted to YES Inc. with your monthly claim packet at proof of receiving products used under CACFP.

Child Care Center Name

MINUTE MENU INSTRUCTIONS: Enter page as receipt into Minute Menu with a value of $0.00. Include form with your claims submission.

Donated or Harvested Food

	Date	Harvested	Donated	Description of Food	Quantity	Donor Name	Donor Contact Info
1
2
3

Donated Milk

	Date	# of Gallons	Quantity	Value of Donation	Whole	Skim/Low-Fat 1%	Iron-Fortified Infant Formula	Alt. Milk	Donor Name	Donor Contact Info
1
2
3
4

ALL DONATED CLAIMS ARE SUBJECT TO VERIFICATION BY YES INC. STAFF. FALSIFICAITON OF RECORDS IS AN OFFENSE THAT IS PUNISHABLE THROUGH SERIOUS DEFINCIENCY AND/OR TERMINATION FROM THE USDA PROGRAM. A CENTER WITH UNSPENT CACFP DOLLARS SHOULD NOT ACCEPT DONATED FOOD. CACFP IS A NONPROFIT FOOD PROGRAM.

Verified at child care site by (signature):

Date