"Supplemental Budget Request Form - Adult Care Food Program" - Florida

This "Supplemental Budget Request Form - Adult Care Food Program" is a part of the paperwork released by the Florida Department of Elder Affairs specifically for Florida residents.

The latest fillable version of the document was released on September 17, 2016 and can be downloaded through the link below or found through the department's forms library.

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Download "Supplemental Budget Request Form - Adult Care Food Program" - Florida

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Adult Care Food Program Supplemental Budget Request Form
This form must be signed annually by ALL providers, even if there are no requests for approval.
Name of Institution _______________________________________________
Contract Number _________________________________________________
Adult Care Food Program institutions must submit prior written request for supplemental budget
items formally “Other” budget items. Please note, there is no extra money awarded or
reimbursed for any items requested. These items, if approved, will only factor in to your facilities
allowable costs.
Examples of items requiring prior specific written approval include, but are not limited to: communication costs,
smoke detectors, fire extinguishers, computer hardware and software, equipment purchases and repairs,
insurance, materials and supplies, legal expenses, professional services, equipment depreciation and use allowance.
Budget Item _________________________________ Budget Amount ________________
Budget Item ________________________________ Budget Amount _________________
Budget Item ________________________________ Budget Amount _________________
No budget items requested at this time.
_________________________________
Signature of Chairperson of the Board,
President of the Board, Owner, or
Delegated Authority
Florida Department of Elder Affairs/ACFP Approval
Approval Date _________
Denial Date __________
Contract Manager _______________________
Unit Manager _______________________
Updated 8/17/16
Adult Care Food Program Supplemental Budget Request Form
This form must be signed annually by ALL providers, even if there are no requests for approval.
Name of Institution _______________________________________________
Contract Number _________________________________________________
Adult Care Food Program institutions must submit prior written request for supplemental budget
items formally “Other” budget items. Please note, there is no extra money awarded or
reimbursed for any items requested. These items, if approved, will only factor in to your facilities
allowable costs.
Examples of items requiring prior specific written approval include, but are not limited to: communication costs,
smoke detectors, fire extinguishers, computer hardware and software, equipment purchases and repairs,
insurance, materials and supplies, legal expenses, professional services, equipment depreciation and use allowance.
Budget Item _________________________________ Budget Amount ________________
Budget Item ________________________________ Budget Amount _________________
Budget Item ________________________________ Budget Amount _________________
No budget items requested at this time.
_________________________________
Signature of Chairperson of the Board,
President of the Board, Owner, or
Delegated Authority
Florida Department of Elder Affairs/ACFP Approval
Approval Date _________
Denial Date __________
Contract Manager _______________________
Unit Manager _______________________
Updated 8/17/16
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