From: "Saved by Windows Internet Explorer 9" Subject: LBNewApplication Date: Tue, 29 May 2012 12:45:57 -0400 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01CD3D98.FE28C320" X-MimeOLE: Produced By Microsoft MimeOLE V6.1.7601.17609 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01CD3D98.FE28C320 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: mhtml:file://C:\Users\rgreene\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\S5BP9K01\LBNewApplication (2).mht LBNewApplication =20 I CERTIFY that the = information on=20 this application is true to the best of my knowledge; that = reimbursement=20 will be claimed only for meals or milk served to children; and = that the=20 school does not discriminate on the basis of race, color,sex, = national=20 origin, age or disability. I further understand that this = information is=20 being given in connection with the receipt of Federal funds, and = that=20 deliberate misrepresentation may subject me to prosecution under=20 applicable State and Federal criminal = statutes. Form FNS-66A = (2-00)=20 Previous Edition Obsolete Notes: Date Last Modified By Last Modified Date Title Signature Region Number State Field Office DoD School Bank=20 Name Bank=20 Acct. Name Bank=20 Acct. # Bank=20 Address City State Zip Bank=20 Routing Transit # Form Approved=20 OMB# 0584-0006 According to the Paperwork Reduction Act of 1995, = no=20 persons are required to respond to a collection of information = unless it=20 displays a valid OMB control number. The valid OMB control number = for this=20 collection is 0584-0006. The Time required to complete this = information is=20 .25 hour per response, including the time to review instructions, = search=20 existing data resources, gather the data needed, and complete and = review=20 the information collection. U.S. Department of Agriculture Food and Nutrition=20 Service NATIONAL SCHOOL LUNCH, BREAKFAST, AND COMMODITY SCHOOL = PROGRAM=20 APPLICATION A. Indicate the Sponsor's Federal Employer = Identification=20 Number (F.E.I.D.) usedto report federal withholding and social=20 security.) B. Attach a copy of letter from IRS documenting = tax-exempt=20 status.. Attached C. Sponsors = must provide=20 assurance of compliance with Title VI of Civil Rights Act of 1964 = by=20 completing Civil Rights Compliance Questionnaire. Attached D. DUNS Number 15. NEW APPLICANTS ONLY:=20 14. I have read the terms of the agreement.=20 13. For private RCCI's: Licensed capacity?=20 Attached= 12. Attach a copy of current license or confirmation = letter for each=20 residentialchild care site.=20 11. Does the school / institution receive or expect to = receive a=20 total of $500,000 or more in federal funds?=20 10. Paid rate only?=20 Lunch Regular Brk SN Brk Reg. Snack Area Elig Snack A. Schools / institutions participating in each=20 category B. Enrollment for schools participating in each=20 category. C.=20 Highest Price charged per meal. 1. Full Price          =20 2.=20 Reduced price          =20 3.=20 Adult price D. Estimated = number of=20 children eligible by category 1. = Full=20 Price 2. Reduced=20 price 3.=20 Free 9. Program data (estimate for agreement year)=20 Sold as = Unit=20 (Pricing) No=20 separate meal charge (Non Pricing) Combination (Pricing and = Non-Pricing) 8. Meals for students are:=20 A. Self-contained kitchen. B. Base Kitchen. C. Satellite / Receiving School / = Institution. D.=20 Central kitchen. E. Vended = meals.7. Number of each food preparation method: A. Beginning date: B. Ending date: C. Est. operating days this year: D. Days in operation per week: E. Months for which claims will not be = submitted: Jul May Jun6. Planned period of food service : (Month/Day/Yr)=20 5. Commodity only sponsor?=20 4. Does sponsor contract with food management = company?=20 A. Private Day School B. Private Boarding School C. Public RCCI D. Private RCCI E. Private RCCI w/ Day Students F. Other3. Number of sites by sponsor type:=20 Name Addr1 Addr2 City   State Zip Tel: Fax: E-Mail 2. Name address and phone of contact person:=20 Addr1 Addr2 City     State Zip Street Addr 1. Mailing address of sponsor:=20 School Year Sponsor Number Sponsor Name County
=20 =20 =20
Print Name
=20 =20 =20 =
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I CERTIFY that the information on this application is true to the best of my knowledge; that reimbursement will be claimed only for meals or milk served to children; and that the school does not discriminate on the basis of race, color,sex, national origin, age or disability. I further understand that this information is being given in connection with the receipt of Federal funds, and that deliberate misrepresentation may subject me to prosecution under applicable State and Federal criminal statutes.
Form FNS-66A (2-00) Previous Edition Obsolete
Notes:
Date
Last Modified By
Last Modified Date
Title
Signature
Region Number
State
Field Office
DoD School
Bank Name
Bank Acct. Name
Bank Acct. #
Bank Address
City
State
Zip
Bank Routing Transit #
Form Approved OMB# 0584-0006
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection is 0584-0006. The Time required to complete this information is .25 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
U.S. Department of Agriculture Food and Nutrition Service
NATIONAL SCHOOL LUNCH, BREAKFAST, AND COMMODITY SCHOOL PROGRAM APPLICATION
A. Indicate the Sponsor's Federal Employer Identification Number (F.E.I.D.) usedto report federal withholding and social security.)
B. Attach a copy of letter from IRS documenting tax-exempt status..
C. Sponsors must provide assurance of compliance with Title VI of Civil Rights Act of 1964 by completing Civil Rights Compliance Questionnaire. Attached
D. DUNS Number
15. NEW APPLICANTS ONLY:
14. I have read the terms of the agreement.
13. For private RCCI's: Licensed capacity?
12. Attach a copy of current license or confirmation letter for each residentialchild care site.
11. Does the school / institution receive or expect to receive a total of $500,000 or more in federal funds?
10. Paid rate only?
Lunch Regular Brk SN Brk Reg. Snack Area Elig Snack
A. Schools / institutions participating in each category
B. Enrollment for schools participating in each category.
C. Highest Price charged per meal.
1. Full Price
          2. Reduced price
          3. Adult price
D. Estimated number of children eligible by category
1. Full Price
2. Reduced price
3. Free
9. Program data (estimate for agreement year)
Sold as Unit (Pricing)
No separate meal charge (Non Pricing)
Combination (Pricing and Non-Pricing)
8. Meals for students are:
A. Self-contained kitchen.
B. Base Kitchen.
C. Satellite / Receiving School / Institution.
D. Central kitchen.
E. Vended meals.
7. Number of each food preparation method:
A. Beginning date:
B. Ending date:
C. Est. operating days this year:
D. Days in operation per week:
E. Months for which claims will not be submitted:
6. Planned period of food service : (Month/Day/Yr)
5. Commodity only sponsor?
4. Does sponsor contract with food management company?
A. Private Day School
B. Private Boarding School
C. Public RCCI
D. Private RCCI
E. Private RCCI w/ Day Students
F. Other
3. Number of sites by sponsor type:
Name
Addr1
Addr2
City  
State
Zip
Tel:
Fax:
E-Mail
2. Name address and phone of contact person:
Addr1
Addr2
City    
State
Zip
Street Addr
1. Mailing address of sponsor:
School Year
Sponsor Number
Sponsor Name
County
Print Name
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