Form HS-3191 "Child and Adult Care Food Program Monthly Racial and Ethnic Data" - Tennessee

What Is Form HS-3191?

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 October 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-3191 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-3191 "Child and Adult Care Food Program Monthly Racial and Ethnic Data" - Tennessee

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Tennessee Department of Human Services
Child and Adult Care Food Program
Monthly Racial and Ethnic Data
Name of Institution:
Address:
Agreement Number:
Ethnic Categories:
Hispanic or Latino
Non-Hispanic and Non-Latino
Racial Categories
American Indian or Native Alaskan
Asian
Native Hawaiian or other Pacific Islander
Black or African American
White
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-3191 (10-15)
Page 1 of 1
Tennessee Department of Human Services
Child and Adult Care Food Program
Monthly Racial and Ethnic Data
Name of Institution:
Address:
Agreement Number:
Ethnic Categories:
Hispanic or Latino
Non-Hispanic and Non-Latino
Racial Categories
American Indian or Native Alaskan
Asian
Native Hawaiian or other Pacific Islander
Black or African American
White
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-3191 (10-15)
Page 1 of 1