"Food Safety Audit and Water Testing Cost-Share Program Application Form" - Delaware

This Delaware-specific printable "Food Safety Audit and Water Testing Cost-Share Program Application Form" is a part of the legal paperwork issued by the Delaware Department of Agriculture.

Download the up-to-date PDF by clicking the link below and mail it as per the guidelines provided by the department.

ADVERTISEMENT

Download "Food Safety Audit and Water Testing Cost-Share Program Application Form" - Delaware

129 times
Rate
(4.4 / 5) 9 votes
Food Safety Audit and Water Testing Cost-Share Program Application
Administered by the Delaware Department of Agriculture
To be eligible for reimbursement the applicant must submit all paperwork to the Delaware Department of Agriculture between
October 1, 2018 and July 31, 2021. The Delaware Department of Agriculture, Food Products Inspection Section, will pay 80%
of the cost of a Delaware Department of Agriculture Authorized USDA AMS or commercial third party food safety audit with a
maximum reimbursement of $1,000 per year, per farm AND 80% of the cost of water testing up to $500 per year, per farm
only once that farm has successfully passed a USDA AMS or commercial food safety audit; until funding source is depleted.
Part 1: General Information
Name of Payee
Contact Person or Business Name (if different than payee)
Name of Farm
Mailing Address
City
State
Zip Code
Primary Telephone Number
Email Address
Social Security or Tax Identification Number for Payee
Location Address, If Different From Mailing Address
City
State
Zip Code
Part 2: Food Safety Audit Support
Date of Certification
Certification Number
Total Amount of Fee for Certification
$ _______________________
Certification Agent/ Agency Address
City
State
Zip
Part 3: Water Testing Support
Total Amount of Fee for Water Testing:
$ ____________________________
Application Page 1 of 2
Food Safety Audit and Water Testing Cost-Share Program Application
Administered by the Delaware Department of Agriculture
To be eligible for reimbursement the applicant must submit all paperwork to the Delaware Department of Agriculture between
October 1, 2018 and July 31, 2021. The Delaware Department of Agriculture, Food Products Inspection Section, will pay 80%
of the cost of a Delaware Department of Agriculture Authorized USDA AMS or commercial third party food safety audit with a
maximum reimbursement of $1,000 per year, per farm AND 80% of the cost of water testing up to $500 per year, per farm
only once that farm has successfully passed a USDA AMS or commercial food safety audit; until funding source is depleted.
Part 1: General Information
Name of Payee
Contact Person or Business Name (if different than payee)
Name of Farm
Mailing Address
City
State
Zip Code
Primary Telephone Number
Email Address
Social Security or Tax Identification Number for Payee
Location Address, If Different From Mailing Address
City
State
Zip Code
Part 2: Food Safety Audit Support
Date of Certification
Certification Number
Total Amount of Fee for Certification
$ _______________________
Certification Agent/ Agency Address
City
State
Zip
Part 3: Water Testing Support
Total Amount of Fee for Water Testing:
$ ____________________________
Application Page 1 of 2
I am a Delaware fruit and/or vegetable grower/packer. I hereby apply to the Delaware Department of Agriculture for cost-
share reimbursement fees under the Cooperative Agreement for the 2018 Specialty Crop Block Grant Program-project
“Market Access Assistance to Delaware Growers through Third Party Food Safety Audit and Water Testing Support”. I
verify that the information I provided on this application is true and correct.
Applicant Signature
Date:
Mail Application and Supporting Documents to:
For Official Use Only
Certificate #
Reimbursement From
Delaware Department of Agriculture
Invoice for Audit:
Food Products Inspection – Cost Share Reimbursement
2320 South DuPont Highway
80% = ___________
$
Dover, Delaware 1901
Reimbursement from
Water Receipts?
Fax: (302) 697-4735
Invoice for Water Test:
____ Yes ____ No
80% = ____________
$
Total Reimbursement: $ ________________________
W-9 Verified By
Date
Approved By
Have you submitted all the required paperwork?
_____ Food Safety Audit Cost-Share Application
_____ Certificate of Successful Audit Completion
_____ Proof of audit payment (Invoice, copy of check, etc…)
_____ Successfully registered with the State of Delaware as a Vendor (W9)
_____ If requesting reimbursement for water testing, submit copies of all receipts
Submit by Email
Print
Application Page 2 of 2
ADVERTISEMENT
Page of 2