Florida Department of Agriculture and Consumer Services
Division of Food, Nutrition and Wellness
SPECIAL MILK PROGRAM
ADAM H. PUTNAM
SPONSOR APPLICATION
COMMISSIONER
Section 595.404, Florida Statutes; 7 CFR Part 215
SCHOOL YEAR - 20___ - 20____
Sponsor Number _______________________________________________________________________
Organization Name _____________________________________________________________________
Sponsor Type
Indicate the type of sponsor (choose one)
Public School District
Private Nonprofit School
Charter School
Camp
Public Residential Child Care Institution (RCCI)
Private Residential Child Care Institution (RCCI)
Private Residential Child Care Institution and Private School (RCCI)
Public Residential Child Care Institution and Public School (RCCI)
Sponsor Address
Sponsor Office Address __________________________________________________________________
Address 2 ____________________________________________________________________________
County____________________________ City ___________________________Zip Code ____________
Sponsor Mailing Address ________________________________________________________________
Sponsor Office Address __________________________________________________________________
Address 2 ____________________________________________________________________________
County____________________________ City ___________________________Zip Code ____________
FDACS-02015 06/15
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Florida Department of Agriculture and Consumer Services
Division of Food, Nutrition and Wellness
SPECIAL MILK PROGRAM
ADAM H. PUTNAM
SPONSOR APPLICATION
COMMISSIONER
Section 595.404, Florida Statutes; 7 CFR Part 215
SCHOOL YEAR - 20___ - 20____
Sponsor Number _______________________________________________________________________
Organization Name _____________________________________________________________________
Sponsor Type
Indicate the type of sponsor (choose one)
Public School District
Private Nonprofit School
Charter School
Camp
Public Residential Child Care Institution (RCCI)
Private Residential Child Care Institution (RCCI)
Private Residential Child Care Institution and Private School (RCCI)
Public Residential Child Care Institution and Public School (RCCI)
Sponsor Address
Sponsor Office Address __________________________________________________________________
Address 2 ____________________________________________________________________________
County____________________________ City ___________________________Zip Code ____________
Sponsor Mailing Address ________________________________________________________________
Sponsor Office Address __________________________________________________________________
Address 2 ____________________________________________________________________________
County____________________________ City ___________________________Zip Code ____________
FDACS-02015 06/15
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Officials
Food Service Director/Manager Name
Position/Job Title______________________________________________________________________
First Name ________________________________________________ Middle Initial ________________
Last Name____________________________________________________________________________
Email ____________________________________________ Fax Number__________________________
Phone Number ____________________________________ Extension____________________________
Reimbursement Claims Official Name ______________________________________________________
Position/Job Title______________________________________________________________________
First Name ________________________________________________ Middle Initial ________________
Last Name____________________________________________________________________________
Email ____________________________________________ Fax Number__________________________
Phone Number ____________________________________ Extension____________________________
Program Information
Type of program (choose one)
Pricing Program with Free Milk option - Milk is provided free to those children who qualify for
free milk based on family income as reported on their Free Milk Application. Milk is sold to other
children participating in the program.
Pricing Program with No Free Milk option. Milk is sold to all children participating in this
program. If this option is selected, enter price charged per 1/2 pint of milk in the textbox below.
Non-Pricing Program. Milk is provided free of charge to all children participating in the program.
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Will the prototype Public Release provided by FNW be used?
Yes
No
NA
Does this sponsor operate any other federal programs?
Yes
No
If Yes, provide the names of the other federal programs.
Does your organization expect to receive a total of $750,000 or more in federal funds from any source
this fiscal year?
Yes
No
NA
If Yes, a copy of the Federal Single Audit must be filed with the Division of Food, Nutrition and Wellness.
The audit is to be submitted within 30 days after receipt of the auditor’s report, but no later than nine
months after the end of the fiscal year period.
Was the milk purchased for the Special Milk Program procured as stated in 7 CFR § 215.14(a)?
Yes
No
Milk must be procured as stated in 215.14a Procurement standards in order to participate in the Special
Milk Program.
Have your organization’s meal counting and claiming procedures changed?
Yes
No
Will the prototype Free Milk Application provided by FNW be used?
Yes
No
Will the prototype Milk Application Instructions provided by FNW be used?
Yes
No
Will the prototype Letter to Parent provided by FNW be used?
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Yes
No
Will the prototype Notification of Eligibility Letter provided by FNW be used?
Yes
No
Applications for Free Milk are approved at:
Central Office
School Level
Other: Please explain ____________________________________________________________
Is computer software used for application approval?
Yes
No
NA
If Yes, provide the name of the software used.
Does the sponsor charge tuition?
Yes
No
If Yes, amount per year:
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