DSS Form 1633 "Application for Participation for Child Care and Adult Day Care Centers in the Child and Adult Care Food Program (CACFP)" - South Carolina

What Is DSS Form 1633?

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

Form Details:

  • Released on January 1, 2013;
  • The latest edition provided by the South Carolina Department of Social 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 DSS Form 1633 by clicking the link below or browse more documents and templates provided by the South Carolina Department of Social Services.

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Download DSS Form 1633 "Application for Participation for Child Care and Adult Day Care Centers in the Child and Adult Care Food Program (CACFP)" - South Carolina

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South Carolina Department of Social Services
APPLICATION FOR PARTICIPATION FOR CHILD CARE AND ADULT DAY CARE
CENTERS IN THE CHILD AND ADULT CARE FOOD PROGRAM (CACFP)
INSTRUCTIONS: Child Care Centers or Adult Day Care Centers must complete this form. A copy should be main-
tained for your file. If a sponsored facility, the original (and required attachments) must be submitted with “Application for
Participation and Management Plan for Sponsoring Organizations.” A copy of this form should be retained by the center
and sponsor, if applicable. Type or print clearly in ink.
1. CACFP Agreement Number:
Federal Identification Number:
2. Name of Center:
3. Physical Address of Center:
Mailing Address:
City:
State:
Zip:
County:
Select County ...
City:
State:
Zip:
Center Telephone: (
)
-
Select County ...
County:
Center Fax: (
)
-
4. Name and Physical Address of Sponsoring Organization:
5A. Name and Title of Person Responsible at Child Care
(Complete only if you operate and/or are applying for two or more
or Adult Day Care Center:
centers.)
5B. Name and Title of CACFP Representative:
(Individual
City:
State:
Zip:
who SCDSS staff can contact for Program Information)
County:
Select County ...
Sponsor Telephone: (
)
-
Sponsor Fax: (
)
-
E-Mail:
6. Type of Facility:
7. Type of Organization:
(Select one)
(Select one and attach appropriate
documentation)
Child:
n
n
n
n
n
n
Child Care Center
Head Start Center
Private Nonprofit Secular
n
n
n
n
Outside-School-Hours Care Center
Private Nonprofit Faith Based
n
n
Private For-Profit (Title XX or Title XIX)
Adult:
n
n
Private For-Profit (F/RP)
n
n
Adult Care Center
n
n
Public Organization (Governmental)
n
n
To be completed by SCDSS staff only:
Educational
n
n
n
n
n
n
n
n
Regular
OSHC
HS
Title XIX
n
n
n
n
Title XX
F/RP
8. Enter Age Range of Participants Accepted at the Center:
9. Is center a nonresidential facility?
n
n
n
n
Yes
No
From:
To:
Note: Only nonresidential facilities are eligible to participate in the
CACFP.
10. Prior Participation in a Food and Nutrition Service Program
A. Has your center ever participated in any of the following
B. Has anyone at the center been a part of any of the
n
n
n
n
programs?
Yes
No
programs listed under 10A that has been terminated as
(If “yes,” place a check mark
in the appropriate box and indicate year.)
n
n
n
n
a result of being seriously deficient ?
Yes
No
n
n
CACFP (Center/DC Home)
n
n
Emergency Shelter
n
n
C. If the answer to question 10B is “yes,” give name(s)
SFSP
n
n
and title(s).
(On a separate sheet, provide current responsibilities
At-Risk After School Snack Program
n
n
for the person who was on a program that was declared seriously
School Breakfast Program
deficient or terminated.)
n
n
National Lunch Program
n
n
Other
DSS Form 1633 (JAN 13) Edition of AUG 07 is obsolete.
Reset
South Carolina Department of Social Services
APPLICATION FOR PARTICIPATION FOR CHILD CARE AND ADULT DAY CARE
CENTERS IN THE CHILD AND ADULT CARE FOOD PROGRAM (CACFP)
INSTRUCTIONS: Child Care Centers or Adult Day Care Centers must complete this form. A copy should be main-
tained for your file. If a sponsored facility, the original (and required attachments) must be submitted with “Application for
Participation and Management Plan for Sponsoring Organizations.” A copy of this form should be retained by the center
and sponsor, if applicable. Type or print clearly in ink.
1. CACFP Agreement Number:
Federal Identification Number:
2. Name of Center:
3. Physical Address of Center:
Mailing Address:
City:
State:
Zip:
County:
Select County ...
City:
State:
Zip:
Center Telephone: (
)
-
Select County ...
County:
Center Fax: (
)
-
4. Name and Physical Address of Sponsoring Organization:
5A. Name and Title of Person Responsible at Child Care
(Complete only if you operate and/or are applying for two or more
or Adult Day Care Center:
centers.)
5B. Name and Title of CACFP Representative:
(Individual
City:
State:
Zip:
who SCDSS staff can contact for Program Information)
County:
Select County ...
Sponsor Telephone: (
)
-
Sponsor Fax: (
)
-
E-Mail:
6. Type of Facility:
7. Type of Organization:
(Select one)
(Select one and attach appropriate
documentation)
Child:
n
n
n
n
n
n
Child Care Center
Head Start Center
Private Nonprofit Secular
n
n
n
n
Outside-School-Hours Care Center
Private Nonprofit Faith Based
n
n
Private For-Profit (Title XX or Title XIX)
Adult:
n
n
Private For-Profit (F/RP)
n
n
Adult Care Center
n
n
Public Organization (Governmental)
n
n
To be completed by SCDSS staff only:
Educational
n
n
n
n
n
n
n
n
Regular
OSHC
HS
Title XIX
n
n
n
n
Title XX
F/RP
8. Enter Age Range of Participants Accepted at the Center:
9. Is center a nonresidential facility?
n
n
n
n
Yes
No
From:
To:
Note: Only nonresidential facilities are eligible to participate in the
CACFP.
10. Prior Participation in a Food and Nutrition Service Program
A. Has your center ever participated in any of the following
B. Has anyone at the center been a part of any of the
n
n
n
n
programs?
Yes
No
programs listed under 10A that has been terminated as
(If “yes,” place a check mark
in the appropriate box and indicate year.)
n
n
n
n
a result of being seriously deficient ?
Yes
No
n
n
CACFP (Center/DC Home)
n
n
Emergency Shelter
n
n
C. If the answer to question 10B is “yes,” give name(s)
SFSP
n
n
and title(s).
(On a separate sheet, provide current responsibilities
At-Risk After School Snack Program
n
n
for the person who was on a program that was declared seriously
School Breakfast Program
deficient or terminated.)
n
n
National Lunch Program
n
n
Other
DSS Form 1633 (JAN 13) Edition of AUG 07 is obsolete.
INSTRUCTIONS FOR DSS FORM 1633
Note: A DSS Form 1633 should be completed for each center.
All Sponsoring Organizations must complete the DSS Form 1613 and a DSS Form 1633 for each sponsored center.
1. The CACFP Agreement Number is assigned by the South Carolina Department of Social Services (SCDSS). If your
organization has not participated in this program before, this number will be entered by SCDSS. If you are adding a
center to your sponsorship, enter agreement number.
Give the Federal Identification Number assigned to your organization by the IRS. This number should be taken from
your tax documents and should agree with the information listed on the W-9 form, which is part of this application
package. If your W-9 indicates that you are a sole proprietor (100% ownership), please include your Social Security
number as well as your Federal Identification Number.
2. Give name and mailing address of the center, including the city, state, zip code and county.
3. Give the physical address of the child care or adult care center. Include the telephone number and fax number for
the center location.
4. If this center is being sponsored by another organization to participate in the CACFP or if your organization is applying
for more than one center to participate in the CACFP, give the name, physical address, telephone number and fax
number of the sponsoring organization.
5. A. Give the name and title of the person in charge at the child care or adult day care center.
B. Give the name and title of the person responsible for CACFP information at the child care or adult day care center.
This is the individual who SCDSS staff can contact for program information. Updates on policy and other
program requirements will normally be mailed to this person’s attention. In addition, give e-mail address if applicable.
6. Check the appropriate item that identifies the facility type.
“Outside-School-Hours Care” (OSHC) center means a public or private nonprofit facility licensed or approved to
provide organized nonresidential child care services to enrolled children, primarily of school age, outside of regular
school hours.
7. Check the appropriate item that identifies the type of institution.
Private Nonprofit centers – must have federal tax exempt status and must have an appropriate Board of Directors
providing oversight to the organization. Churches can provide a copy of their certificate of Nonprofit Status issued by
the Secretary of State’s office.
Private For-Profit Title XX or Title XIX organization – must provide documentation that at least 25% of the enrollees,
or licensed capacity, whichever is less, are either Title XX recipients (adult or child care), or Title XIX recipients (adult
care) for the month prior to submission of application.
Private F/RP (child care) – must provide documentation that at least 25% of the children enrolled in your center, or
licensed capacity, whichever is less, are eligible for free or reduced-price meals.
Public organizations are a part of local, state or federal government.
Educational organizations are colleges, universities, schools, etc.
8. Enter age range of participants accepted at the center.
9. To be eligible for participation, all centers must be nonresidential and have federal, state or local licensing to operate
as a child care, adult care, head start or OSHC center.
10. A. If you check “yes,” please make sure you place a check mark in the appropriate box. If you are renewing your
contract with SCDSS, you should check “yes.”
B. and C. Organizations that 1) have been declared seriously deficient and terminated from program participation or
2) that employ individuals that have been a part of a program that was declared seriously deficient and
terminated may not be approved to participate in the CACFP.
DSS Form 1633 (JAN 13)
PAGE 1A
11. Operating Data
11A. Hours of Operation:
11B. Number of Staff at this Facility:
(Include Director/Owner)
From:
To:
11C. Place a Check Mark by the Days of Operation:
11D. Number of Operating Weeks Per Year:
n
n
n
n
n
n
n
n
n
n
n
n
n
n
M
T
W
T
F
S
S
11E. Does center receive Title III meal funding or
11F. List any months or period during which the Child and
commodities? If yes, please explain on a separate
Adult Care Food Program will not operate:
(Include
n
n
n
n
dates of closing and reopening.)
sheet.
Yes
No
12. Meal Service
(Complete only for meals you are requesting reimbursement)
AM
PM
Evening
Breakfast
Lunch
Supper
Supplement
Supplement
Supplement
12A. Time of Meal Service
12B. No. of Meals Expected
to be Served Per Day
n
n
n
n
13. Does the center provide care in shifts?
Yes
No
If yes, complete question 15.
14. Is the center requesting reimbursement for more than two meals and one snack or two snacks and one meal?
n
n
n
n
Yes
No
If yes, complete question 15.
15. If you responded yes to question 13 or 14, identify the times of each shift at this center and the meals that will be
served at each shift.
Shift Times
Meals to be claimed for reimbursement
First Shift
Second Shift
Third Shift
16. Total Enrollment for this Center:
17. Provide the License Capacity for this Center:
License Expiration Date:
License No.:
18. Method by which meals will be provided. Identify the meal type for each method used by this center.
(For example,
Breakfast, Lunch, PM Snack, for each method used.)
A. Meals Prepared at the Service Location:
B. Meals Prepared at the Central Kitchen:
Provide Physical Address of Central Kitchen:
C. Meals Provided by a Local School System*:
D. Meals Prepared by a Food Service Management Co.*:
* Attach Copy of Contract
19. Method of Reimbursement:
20. Do you charge a separate fee for meals?
(Check one)
(Check one)
n
n
n
n
n
n
Actual
Claiming Percentage
Yes
(Pricing Program)
n
n
Note: Record keeping requirements are different for each method.
No
(Non-Pricing Program)
If you selected the actual method of reimbursement, you must
maintain the actual meal count record (DSS Form 1642).
DSS Form 1633 (JAN 13)
PAGE 2
INSTRUCTIONS FOR DSS FORM 1633, CONTINUED
11. A. - F. Enter operating data as requested.
Title III funding refers to funds associated with the Older Americans Act.
12. A. Indicate the start time for each meal type for which you are requesting reimbursement. A maximum of two meals
and one snack or two snacks and one meal served will be reimbursed per participant.
B. For each meal type you are requesting reimbursement, indicate the number of meals that you anticipate serving
per day. This number should not be greater than the center’s total enrollment.
13. Self-explanatory.
14. Self-explanatory.
16. List center’s current total enrollment.
17. Indicate the center’s license capacity, license expiration date and license number. Adult day care centers must
submit a copy of the license with this application.
18. Identify how each meal and snack that will be claimed for reimbursement will be provided for this center. For
example, if breakfast, lunch and PM snacks are prepared at the center, list these meal service types (breakfast,
lunch and PM snack) on the line beside “Preparation at Meal Service Location”.
Include a copy of the current contract with the school of Food Service Management Company if this function is
contracted. It may be necessary to complete more than one item.
19. Select a method of reimbursement. Actual means that each meal served to each participant will be counted
individually and the category of eligibility will need to be documented by meal. Claiming Percentage means that a
“general” meal count will be taken at the time of meal service. The reimbursement for Claiming Percentage is based
upon the percentage of free, reduced and paid participants enrolled during a given month. This percentage is then
calculated against the total number of meals claimed and the reimbursement calculated accordingly. The main
difference between the two is the way meals are counted. With Claiming Percentage, there is only a generalized
meal count; with Actual, every participant’s meals and category must be tabulated.
20. Indicate if your center is structured as a pricing or non-pricing center. Pricing means you charge a separate fee for
meals; non-pricing means you charge one price that includes meals.
21. Indicate your preference. Currently, donated foods are not available in South Carolina. Therefore, you must check
the box for USDA-Donated Food.
22./23. Federal regulations require that an organization include as part of its CACFP application the name and date of
birth of Principals and/or responsible individuals. Principals of an organization include, but are not limited to the
Chairperson, Executive Director, Owner or individuals with the equivalent title within an organization. Responsible
individuals are individuals who have oversight of the program. If more space is needed, attach a separate sheet
of paper.
DSS Form 1633 (JAN 13)
PAGE 2A
n
n
n
n
21. Applicant organization would prefer to receive:
USDA-DONATED FOOD
CASH PAYMENTS
(Approved applicants which prefer cash payments instead of donated foods will receive such payments. However, those who choose foods may
be required to accept cash instead.)
22. Responsible Individuals of the Organization: Responsible individuals are individuals who have oversight of the program.
Name
Title
Date of Birth
23. Principals of the Organization: These include but are not limited to the Chairperson, Executive Director, Owner or
individuals with the equivalent title within an organization.
Name and Date(s) of Publicly Funded Programs
Name
Title
Date of Birth
Individual Participated in During Past Seven Years
24. List the name and date(s) of the publicly funded programs this center has participated in during the past seven years.
Name of Program/Dates of Participation
Name of Program/Dates of Participation
CERTIFICATION STATEMENT
25. I CERTIFY that during the past seven years the applicant center has not been disqualified from participation in any
other publicly-funded program for violating program’s requirements. I understand that “publicly-funded program”
means any program or grant funded by federal, state or local government. Initial:
Date:
26. I CERTIFY that the information on this application, including all attachments, is true to the best of my knowledge;
that I will accept final administrative and financial responsibility for total Child and Adult Care Food Program
operations at this facility and that reimbursement will be claimed only for meals served to enrolled participants; that
the CACFP will be available to all eligible participants without regard to race, color, sex, national origin, age or
disability at this food service facility and that this facility has the capability for the meal service planned for the number
of participants anticipated to be served. 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. Initial:
Date:
Note: The individual completing number 25 and number 26 must be the same as the signature below, and the individual’s name must be listed
on item number 1 on the Statement of Authority.
Date:
Name and Title of Center Representative:
Signature of Center Representative:
Date:
Name and Title of Administrator:
Signature of Administrator:
(Authorized
(Authorized sponsoring
sponsoring organization representative; print or type)
organization representative)
DSS Form 1633 (JAN 13)
PAGE 3
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