Form HS-3083 "Claim for Reimbursement Child and Adult Care Food Program (Homes Only)" - Tennessee

What Is Form HS-3083?

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-3083 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-3083 "Claim for Reimbursement Child and Adult Care Food Program (Homes Only)" - Tennessee

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Tennessee Department of Human Services
CLAIM FOR REIMBURSEMENT
CHILD AND ADULT CARE FOOD PROGRAM (HOMES ONLY)
1. Check Appropriate
2. Check Appropriate
4. Name and Address of Institution:
Claim Type
Submission Type
Timely Submission
Original Claim
Late Submission
Revised Claim (Based
on Monitoring
Y
N)
3. Agreement Number
5.
BREAKFAST
LUNCHES
SUPPERS
SUPPLEMENTS
TOTAL
A. TIER I (ONLY)
B. TIER II (ONLY)
C. TIER II MIXED (ONLY)
TIER I RATES
TIER II RATES
6. Total Attendance
A. TIER I (only)
B. TIER II (only)
C. Mixed
for Claim Period
TIER I
TIER II
D. Grand Total
(TIER I (only) + TIER II (only) + Mixed)
7. Actual Operating and Administrative
8. # of Adult
9. Actual number of Day Care Homes
Expenses for Reporting Month for this Contract:
Meals Served
operating this claim period
Administrative Salaries
$
TIER I
TIER II
Mixed
Total
(only)
(only)
Administrative Benefits
$
Printing
$
10. Do you receive any other money
from other CACFP Programs?
Office Supplies
$
Yes
No
Program Income
Communications
$
Staff Training
$
$
If yes, please list the contracts:
Indirect Costs
$
Occupancy
$
Utilities
$
Travel
$
Contracted Services
$
Other-Specify
$
13. Children Enrolled in Homes
A. TIER I
B. TIER II (only)
C. Mixed
for this Claim Period
(only)
TIER I
TIER II
D. Grand Total
TIER I (only)+ TIER II (only)+ Mixed
11. Remarks
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-3083 (rev 9-15)
Page 1
Tennessee Department of Human Services
CLAIM FOR REIMBURSEMENT
CHILD AND ADULT CARE FOOD PROGRAM (HOMES ONLY)
1. Check Appropriate
2. Check Appropriate
4. Name and Address of Institution:
Claim Type
Submission Type
Timely Submission
Original Claim
Late Submission
Revised Claim (Based
on Monitoring
Y
N)
3. Agreement Number
5.
BREAKFAST
LUNCHES
SUPPERS
SUPPLEMENTS
TOTAL
A. TIER I (ONLY)
B. TIER II (ONLY)
C. TIER II MIXED (ONLY)
TIER I RATES
TIER II RATES
6. Total Attendance
A. TIER I (only)
B. TIER II (only)
C. Mixed
for Claim Period
TIER I
TIER II
D. Grand Total
(TIER I (only) + TIER II (only) + Mixed)
7. Actual Operating and Administrative
8. # of Adult
9. Actual number of Day Care Homes
Expenses for Reporting Month for this Contract:
Meals Served
operating this claim period
Administrative Salaries
$
TIER I
TIER II
Mixed
Total
(only)
(only)
Administrative Benefits
$
Printing
$
10. Do you receive any other money
from other CACFP Programs?
Office Supplies
$
Yes
No
Program Income
Communications
$
Staff Training
$
$
If yes, please list the contracts:
Indirect Costs
$
Occupancy
$
Utilities
$
Travel
$
Contracted Services
$
Other-Specify
$
13. Children Enrolled in Homes
A. TIER I
B. TIER II (only)
C. Mixed
for this Claim Period
(only)
TIER I
TIER II
D. Grand Total
TIER I (only)+ TIER II (only)+ Mixed
11. Remarks
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-3083 (rev 9-15)
Page 1
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.
12. Signature of Authorized
13. Title
14. Preparation Date
Representative
____________________________
___________________________
/
/
All receipts, invoice and other evidence of purchase must be retained and
No further reimbursement shall be paid under the CACFP for the period
available for future audit for a period of 3 years after the end of the fiscal year
covered by this claim unless this is completed and filed as required by the
to which they pertain.
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-3083 (rev 9-15)
Page 2
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