DSS Form 1613-2 "Fiscal Resources and Financial History" - South Carolina

What Is DSS Form 1613-2?

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 June 1, 2012;
  • 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 printable version of DSS Form 1613-2 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 1613-2 "Fiscal Resources and Financial History" - South Carolina

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South Carolina Department of Social Services
Child and Adult Care Food Program
FISCAL RESOURCES AND FINANCIAL HISTORY
Institution:
Information Current as of:
Instructions: Describe all the activities the institution conducts other than the Child and Adult Care Food Program. You
may attach the description if it is labeled “Fiscal Resources and Financial History.”
Institution’s Fiscal Year:
(Tax year)
Total Non-CACFP revenue to the institution for current fiscal year:
(Example: ABC/Medicaid Payments, Head Start funds, Tuition, etc.)
Dates of Reporting Period:
to
1
Amount in $
Source
Frequency
How long has
Will the funding
Comments
this funding been
change in the next
available?
fiscal year?*
1
Identify if funds are federal.
*If the funding is going to change in level, function or nature, please describe the impact it will have on the organization.
Name of Authorized Representative:
Signature of Authorized Representative:
Date:
DSS Form 1613-2 (JUN 12) Edition of JUN 10 is obsolete.
South Carolina Department of Social Services
Child and Adult Care Food Program
FISCAL RESOURCES AND FINANCIAL HISTORY
Institution:
Information Current as of:
Instructions: Describe all the activities the institution conducts other than the Child and Adult Care Food Program. You
may attach the description if it is labeled “Fiscal Resources and Financial History.”
Institution’s Fiscal Year:
(Tax year)
Total Non-CACFP revenue to the institution for current fiscal year:
(Example: ABC/Medicaid Payments, Head Start funds, Tuition, etc.)
Dates of Reporting Period:
to
1
Amount in $
Source
Frequency
How long has
Will the funding
Comments
this funding been
change in the next
available?
fiscal year?*
1
Identify if funds are federal.
*If the funding is going to change in level, function or nature, please describe the impact it will have on the organization.
Name of Authorized Representative:
Signature of Authorized Representative:
Date:
DSS Form 1613-2 (JUN 12) Edition of JUN 10 is obsolete.