Form SFN53379 "Child and Adult Care Food Program Affiliation Disclosures" - North Dakota

What Is Form SFN53379?

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

Form Details:

  • Released on June 1, 2004;
  • The latest edition provided by the North Dakota Department of Public Instruction;
  • 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 SFN53379 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Public Instruction.

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Download Form SFN53379 "Child and Adult Care Food Program Affiliation Disclosures" - North Dakota

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CHILD AND ADULT CARE FOOD PROGRAM AFFILIATION DISCLOSURES
NORTH DAKOTA DEPARTMENT OF PUBLIC INSTRUCTION
SFN 53379 (06/04)
Local Agency Name
Instructions: Complete only part A if center is a church-based program or only part B if center
is a homeless shelter.
A. Church Affiliation Certification
On behalf of
, I certify that
________________________________________
________________________________________
(Name of church)
(Name of center)
has a direct affiliation with the above named church. The following statements of affiliation apply
(mark all that apply):
The center lists the church in its articles of incorporation.
The center is considered an asset of the church (listed as an asset in the financial statement of
the church).
The center reports to the church regarding activities and/or financial activities.
Signature, Church Representative
Title
Date
B. Homeless Shelter Certification
Name of Shelter
Describe how the shelter will ensure that reimbursement will only be claimed for meals served to eligible children who reside at the shelter:
The primary purpose of this shelter is to temporarily house and provide meals to children and their parents/guardians.
Yes
No
Signature, Authorized Representative
Date
CHILD AND ADULT CARE FOOD PROGRAM AFFILIATION DISCLOSURES
NORTH DAKOTA DEPARTMENT OF PUBLIC INSTRUCTION
SFN 53379 (06/04)
Local Agency Name
Instructions: Complete only part A if center is a church-based program or only part B if center
is a homeless shelter.
A. Church Affiliation Certification
On behalf of
, I certify that
________________________________________
________________________________________
(Name of church)
(Name of center)
has a direct affiliation with the above named church. The following statements of affiliation apply
(mark all that apply):
The center lists the church in its articles of incorporation.
The center is considered an asset of the church (listed as an asset in the financial statement of
the church).
The center reports to the church regarding activities and/or financial activities.
Signature, Church Representative
Title
Date
B. Homeless Shelter Certification
Name of Shelter
Describe how the shelter will ensure that reimbursement will only be claimed for meals served to eligible children who reside at the shelter:
The primary purpose of this shelter is to temporarily house and provide meals to children and their parents/guardians.
Yes
No
Signature, Authorized Representative
Date