Form HS-3069 "Claim for Reimbursement Child and Adult Care Food Program" - Tennessee

What Is Form HS-3069?

This is a legal form that was released by the Tennessee Department of Human Services - a government authority operating within Tennessee. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2015;
  • The latest edition provided by the Tennessee Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HS-3069 by clicking the link below or browse more documents and templates provided by the Tennessee Department of Human Services.

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Download Form HS-3069 "Claim for Reimbursement Child and Adult Care Food Program" - Tennessee

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Tennessee Department of Human Services
CLAIM FOR REIMBURSEMENT
CHILD AND ADULT CARE FOOD PROGRAM
1. Check Appropriate
2. Check Appropriate
4. Name and Address of Institution:
Claim Type
Submission Type
Original Claim
Timely Submission
Revised Claim ( Based
Late Submission
on Monitoring
Y
N)
3. Agreement Number
5. Month and Year Claimed
6. Total Number of Days Food Service
was Provided for Period Claimed
Month
Year
7. Total Attendance for
8. Eligible Proprietary
Claim Period
Title XX Centers (Child)
or Title XIX Centers
A. Child or Adult Care
B. Outside School
C. Eligible for Proprietary
(Adult)
Centers
Hour
Title XX/Title XIX Centers
Total Number of Meals Served to Participants in Child/Adult Care Centers
A. Breakfasts
B. Lunches
C. Suppers
D. Snacks
9. Free
10. Reduced
11. Paid
(Required for all Claims)
12. Total
13. Total Number of Participants Enrolled
Free
Paid
Reduced
in Centers for this Claim Period
14. Actual Operating and Administrative Expenses for Reporting Month for this Contract:
Category
Month Ending
Year to Date
Total
Administrative Salaries
$
$
Administration Benefits
$
$
Printing
$
$
Office Supplies
$
$
Communications
$
$
Staff Training
$
$
Indirect Costs
$
$
Occupancy
$
$
Utilities
$
$
Travel
$
$
Contracted Services
$
$
Other-Specify
$
$
DHS staff should check the “Forms” section of the intranet to ensure the use of current versions. Forms may not be altered without prior approval.
Distribution: CACFP Providers
RDA: Pending
HS-3069 (rev 9-15)
Page 1
Tennessee Department of Human Services
CLAIM FOR REIMBURSEMENT
CHILD AND ADULT CARE FOOD PROGRAM
1. Check Appropriate
2. Check Appropriate
4. Name and Address of Institution:
Claim Type
Submission Type
Original Claim
Timely Submission
Revised Claim ( Based
Late Submission
on Monitoring
Y
N)
3. Agreement Number
5. Month and Year Claimed
6. Total Number of Days Food Service
was Provided for Period Claimed
Month
Year
7. Total Attendance for
8. Eligible Proprietary
Claim Period
Title XX Centers (Child)
or Title XIX Centers
A. Child or Adult Care
B. Outside School
C. Eligible for Proprietary
(Adult)
Centers
Hour
Title XX/Title XIX Centers
Total Number of Meals Served to Participants in Child/Adult Care Centers
A. Breakfasts
B. Lunches
C. Suppers
D. Snacks
9. Free
10. Reduced
11. Paid
(Required for all Claims)
12. Total
13. Total Number of Participants Enrolled
Free
Paid
Reduced
in Centers for this Claim Period
14. Actual Operating and Administrative Expenses for Reporting Month for this Contract:
Category
Month Ending
Year to Date
Total
Administrative Salaries
$
$
Administration Benefits
$
$
Printing
$
$
Office Supplies
$
$
Communications
$
$
Staff Training
$
$
Indirect Costs
$
$
Occupancy
$
$
Utilities
$
$
Travel
$
$
Contracted Services
$
$
Other-Specify
$
$
DHS staff should check the “Forms” section of the intranet to ensure the use of current versions. Forms may not be altered without prior approval.
Distribution: CACFP Providers
RDA: Pending
HS-3069 (rev 9-15)
Page 1
15. Do you receive any other money from other CACFP Programs?
Yes
No
If yes, please list these contracts:
I certify that the information on this application and the attached Site Information Document(s), is true to the best of my knowledge, that
reimbursements will be claimed only for meals served to eligible children at approved food service sites, and that these sites have been visited and
have the capability and facilities for the meal service planned for the number of children anticipated to be served and that the organization will
directly operate the Program in accordance with 7 CFR 225.14(d)(3). I 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. The
program must be made available to all eligible children regardless of race, color, national origin, sex, age or disability. If government sponsor, I
certify that the program is directly operated at all sites.
16. Signature of Authorized
17. Title
18. Preparation Date
Representative
___________________________
___________________________
/
/
All receipts, invoice and other evidence of purchase must be retained and available for future
No further reimbursement shall be paid under the CACFP for the
audit for a period of 3 years after the end of the fiscal year to which they pertain.
period covered by this claim unless this is completed and filed as
required by the Tennessee Department of Human Services and the
Federal Regulations at 7 CFR Part 226
DHS staff should check the “Forms” section of the intranet to ensure the use of current versions. Forms may not be altered without prior approval.
Distribution: CACFP Providers
RDA: Pending
HS-3069 (rev 9-15)
Page 2
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