"Annual Information Certification Form - Adult Care Food Program (Acfp)" - Florida

Annual Information Certification Form - Adult Care Food Program (Acfp) is a legal document that was released by the Florida Department of Elder Affairs - a government authority operating within Florida.

Form Details:

  • Released on July 20, 2018;
  • The latest edition currently provided by the Florida Department of Elder Affairs;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;

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Download "Annual Information Certification Form - Adult Care Food Program (Acfp)" - Florida

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Adult Care Food Program (ACFP)
Annual Information Certification
This is to certify that
meets all of the requirements for renewing
Name of Institution
institutions contained in 7 CFR §226.6(b)(2). This means
Name of Institution
certifies that:
For Sponsoring organizations only:
The management plan on file with the State agency is complete and up to date;
No sponsored facility or principal of a sponsored facility is currently on the CACFP National Disqualified
List; and
The outside employment policy most recently submitted to the State agency remains current and in
effect.
For all institutions (sponsoring organizations and independent centers):
The names, mailing addresses, and dates of birth of all current institution principals have been
submitted to the State agency;
The online application has been updated and is correct for the upcoming fiscal year;
Any change of information for the point of contact, institution information, board president or
authorized designee, center/facility information, and signature authority changes for claims has
been updated and submitted to the State agency using the Change of Information form.
The current food service contract, memorandum of agreement or ITB, has been approved by the
State agency. This is not applicable to self-prep institutions;
The current adult day care license, mental health day program contract, or community-based
services provider certificate have been submitted to the State agency;
The Public News Release form with free and reduced-price meal policy statement and the
nondiscrimination policy has been submitted to public media for broadcasting or printing. The
completed form has been submitted to the State agency;
The cycle of menus, four week cycle, has been submitted to the State agency for each reimbursable
meal and/or snack;
The Institution itself, and the Institution’s principals, are not currently on the CACFP
National Disqualified List;
The list of any publicly funded programs institution and principals have participated in the past seven
years is current. The Certification of Business Integrity form has been submitted to the State agency;
The Institution itself, and the Institution’s principals, have not been determined ineligible for any other
publicly funded programs due to violation of that Program’s requirements in the past seven years;
Revised 7/20/2018
Adult Care Food Program (ACFP)
Annual Information Certification
This is to certify that
meets all of the requirements for renewing
Name of Institution
institutions contained in 7 CFR §226.6(b)(2). This means
Name of Institution
certifies that:
For Sponsoring organizations only:
The management plan on file with the State agency is complete and up to date;
No sponsored facility or principal of a sponsored facility is currently on the CACFP National Disqualified
List; and
The outside employment policy most recently submitted to the State agency remains current and in
effect.
For all institutions (sponsoring organizations and independent centers):
The names, mailing addresses, and dates of birth of all current institution principals have been
submitted to the State agency;
The online application has been updated and is correct for the upcoming fiscal year;
Any change of information for the point of contact, institution information, board president or
authorized designee, center/facility information, and signature authority changes for claims has
been updated and submitted to the State agency using the Change of Information form.
The current food service contract, memorandum of agreement or ITB, has been approved by the
State agency. This is not applicable to self-prep institutions;
The current adult day care license, mental health day program contract, or community-based
services provider certificate have been submitted to the State agency;
The Public News Release form with free and reduced-price meal policy statement and the
nondiscrimination policy has been submitted to public media for broadcasting or printing. The
completed form has been submitted to the State agency;
The cycle of menus, four week cycle, has been submitted to the State agency for each reimbursable
meal and/or snack;
The Institution itself, and the Institution’s principals, are not currently on the CACFP
National Disqualified List;
The list of any publicly funded programs institution and principals have participated in the past seven
years is current. The Certification of Business Integrity form has been submitted to the State agency;
The Institution itself, and the Institution’s principals, have not been determined ineligible for any other
publicly funded programs due to violation of that Program’s requirements in the past seven years;
Revised 7/20/2018
No principals of the Institution have been convicted of any activity that occurred during the past seven
years and that indicated a lack of business integrity; and
The Institution is currently compliant with the required performance standards of financial viability
and management, administrative capability, and program accountability as described in 7 CFR
§226.6(b)(2)(vii).
Does your facility expend $750,000 or more per fiscal year in federal funds? Yes ____ or No ____.
If you do expend $750,000 or more per fiscal year, have you met all audit requirements set forth in
2 CFR part 200, subpart F? Yes ____ or No ____.
Do you operate an Adult Day Care Program in another state? Yes ______ No _____
If yes, which states? ___________________________________________________
Any of the above information that has changed since the initial application has already been submitted
to the State agency or is being submitted with this certification.
I certify that the above information is true and correct.
Date
Name of Board Chair, Executive Director,
or individual with comparable title
Title
Revised 7/20/2018
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