HomeMy WebLinkAbout12-039 - Office of Superintendent of Public Instruction - Child Care Food Program ReimbursementOFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
Child Nutrition Services
Old Capitol Building
PO BOX 47200
OLYMPIA WA 98504 -7200
CHILD AND ADULT CARE FOOD PROGRAM
PROCUREMENT STANDARDS
12- 039(a)
Council Approval N/A
AGREEMENT NUMBER
I
The procurement standards are a combination of the provisions contained in the U.S. Department of Agriculture, Food and
Nutrition Service regulations and other federal regulations as follows:
• U.S. Department of Agriculture, Food and Nutrition Service regulations.
• 7 CFR Part 226 Child and Adult Care Food Program.
• 7 CFR 3019 Uniform Administrative Requirement for Non - Profit Organizations.
• 7 CFR 3016 Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local
Governments.
• OMB Circular A -122 Allowability of Costs for Non - Profit Organizations.
• FNS Instruction 796 -2 Revision 3 Allowable Cost Rules.
More restrictive standards may apply per state law or organization procurement policies and procedures.
These standards are a mandatory requirement and apply to all items purchased by institutions for food, supplies,
equipment, and other goods and services. This document applies to all officers, employees, and agents acting on behalf of
the institution. If a conflict arises between these procedures and those established by a government body, procedures that
bear legal superiority will take precedence.
Procurement Procedures
All institution procurements must comply with USDA Memorandum CACFP 01 -2013 and with 7 CFR 226.22 (d)
through (h) sections. All institutions who estimate a purchase greater than or equal to $150,000 must formally
procure this purchase. Institution types will follow procedures as set forth:
• Proprietary (for - profit) institutions -7 CFR 226.22.
• Private nonprofit institutions -7 CFR 3019.41 through 7 CFR 3019.48.
• Public agency institutions -7 CFR 3016.36.
In all of the above cases, if there are regulations or institution policies and procedures establishing a small
purchase threshold less than $150,000, then a formal procurement process is required for goods and services.
For public agency institutions a person or entity that develops or drafts specifications, requirements, statements of
work, invitations for bid, requests for proposals, contract terms and conditions, or documents specifically for use
by an institution in conducting procurement shall be excluded from competing for such procurements per 7 CFR
Part 3016.36[b].
Pursuant to Sec. 3016.36(b)(12), public agency institutions must have protest procedures in place to handle and
resolve disputes relating to their procurements and must in all instances disclose information regarding a protest
to their state agency.
An institution may not sign a contract with a party that has been debarred or suspended (i.e., is ineligible) per
7 CFR 3017. Non - federal entities are prohibited from contracting with or making subawards under covered
transactions to parties that are suspended or debarred or whose principals are suspended or debarred. Covered
transactions included procurement contracts for goods or services equal to or in excess of $25,000. When a non-
federal entity enters into a covered transaction with an entity at a lower tier, the non - federal entity must verify that
the entity is not suspended or debarred or otherwise excluded. This verification may be accomplished by checking
the System for Award Management (SAM) website maintained by the federal government at www.sam.gov,
collecting a certification from the entity, or adding a clause or condition to the covered transaction with that entity.
Institutions should keep documentation of this verification.
FORM SPI CNS 1136PS (Rev. 10/12)
1
OSPI /Child Nutrition Services
Attachment 4 to Bulletin No. 030 -13 CNS
August 2013
There are two types of procurement procedures depending on the total costs:
A. For all institutions, purchases greater than $150,000 are considered a large purchase and must include
one or more of the following methods of procurements: Invitation for Bid (IFB) or Request for Proposal
(RFP) or sole source. Descriptions of each procedure are provided below (see also General Provisions):
1. Invitation for Bid (IFB)
This procedure will be used when an adequate and realistic product or service description is
available. It will not be used unless there are two more responsible suppliers willing and able to
compete effectively for the business and there is every intention of selecting the successful bidder
principally on the basis of price. No awards will be made under this procedure unless at least two
bids have been received.
Formally advertised, sealed bids are publicly solicited and a firm fixed price contract is awarded to
the responsible bidder whose bid conforms to the terms and conditions of the IFB.
a. Institutions must meet the following requirements when formally advertising an invitation
for bid:
(1)
Institutions must advertise and publicly announce the proposed contract at least
14 calendar days before the opening of bids. The announcement must include
the time and place of the bid opening and information about obtaining a copy of
the complete specification for the institution's proposed purchase.
(2) At least two weeks before the bid opening date, bids will be solicited from an
adequate number of known suppliers. These shall include suppliers listed in the
local telephone book, purchasing directors, or names of suppliers on solicitation
lists to include minority, small, and women's business enterprises. In addition, the
invitation to bid will be posted in a public place or otherwise advertised.
(3)
A complete, adequate, and realistic specification or purchase description will be
part of the IFB. Menus will be part of any solicitation for a food service
management company.
(a) Only nonfood items necessary for the food service (such as straws,
napkins, or packaging) can be included in the IFB.
(b) The IFB must be so clear and accurate that all prospective bidders will
have an equal chance of award of the contract.
(c) The IFB may not provide for loans or other monetary benefits, terms, or
conditions to be made to institutions by commercial vendors.
(4) Factors such as price, quality, ability to perform, character, deadlines, prior
experience, etc., as well as discounts, transportation costs, and life cycle costs
will be considered in determining which bid is low only if so specified in the IFB.
(5)
Any or all bids may be rejected when there are sound documented business
reasons in the best interest of the program.
(6) A written notice of award shall be made to that responsible bidder, whose bid,
conforming to the IFB, is lowest. •
(7) All bids shall be opened publicly at the time and place stated in the IFB.
(8) If the institution is not accepting the lowest bid, a justification for awarding the
contract to a higher bidder must be provided.
FORM SPI CNS 1136PS (Rev. 10/12)
2
OSPI /Child Nutrition Services
Attachment 4 to Bulletin No. 030 -13 CNS
August 2013
2. Request for Proposal (RFP)
This procedure, also called competitive negotiation, will be used when it is impossible to prepare a
realistic specification or the award cannot be made principally on the basis of price. In competitive
negotiation, a request for proposal will be publicized and a number of suitable sources will be
requested to submit proposals. Negotiations will be conducted with two or more of the firms
submitting offers. This method may be used only if conditions are not appropriate for the use of
formal advertising (IFB's).
a. Procedures are as follows:
(1) Requests for proposal shall outline the procedures and evaluation factors that will
be used to identify and select responsible offerors for negotiation as well as the
criteria that will be used to make the final selection for contract award.
(2) Award will be made to the responsible offeror whose proposal will be most
advantageous to the sponsor with price and other factors considered.
Unsuccessful offerors will be notified immediately when a contractor is selected.
3. Sole Source
This is noncompetitive negotiation in procurements through solicitation of a proposal from only
one source. Noncompetitive negotiation may be used only when award of the contract is not
feasible under the IFB or RFP procedures.
a. Noncompetitive negotiations are limited to the following:
(1) The item is available only from a single source.
(2) An emergency requirement exists.
(3) Competition is determined to be inadequate.
(4) OSPI authorizes noncompetitive negotiation.
B. Institutions with aggregate purchases less than the $150,000 small purchase threshold may use an
informal process. An aggregate amount is the sum total of materials or services which can logically be
purchased from one vendor during one fiscal year. Institutions must have documented evidence of open
and free competition at the best price. Price or rate quotations must be obtained from an adequate
number of qualified sources. Small purchases shall be documented. At a minimum, documentation shall
include the date, vendors contacted, item description, prices quoted, and any delivery data. Whenever
only one quotation is received, documentation must include written justification for the purchase. The
following procedure must be observed:
Small Purchase Procedures
1. Price comparisons may be used.
2. Institution policy and procedures may require an IFB or RFP under the $150,000 small purchase
threshold which is permissible and encouraged.
II. General Provisions —for IFB, RFP, Sole Source
Award Approval
OSPI must approve contracts that meet the following criteria. The procurement is proposed as a sole source
procurement and will be awarded without competition.
FORM SPI CNS 1136PS (Rev. 10/12)
3
OSPI /Child Nutrition Services
Attachment 4 to Bulletin No. 030 -13 CNS
August 2013
Geographic Preference
Section 9(j) of the Richard B. Russell National School Lunch Act was amended by the 2008 Farm Bill to
encourage institutions to use a geographic preference when purchasing unprocessed agricultural products, both
locally grown and locally raised. The geographic preference does not guarantee a certain percentage or level of
business, but gives bidders located in a certain geographic area a specific and defined advantage in the
procurement process.
III. Code of Conduct
This code of conduct shall govern the performance of all officers, employees, and agents engaged in the award
and administration of contracts supported by federal funds.
A. It shall be a breach of ethical standards for any employee, officer, or agent to participate directly or
indirectly in the selection, award, or administration of a contract supported by federal funds when the
employee knows that:
1. The employee, officer, agent, or any member of his immediate family has a financial or other
interest pertaining to the procurement.
2. A business or organization in which the officer, employee, agent, or any member of his immediate
family has a financial or other interest pertaining to the procurement.
3. Any other person, business, or organization which the employee, officer, agent, or any member of
his immediate family is negotiating with or has an arrangement concerning prospective
employment is involved in the procurement.
B. All officers, employees, or agents shall neither solicit nor accept gratuities, favors, or anything of monetary
value from contractors, potential contractors, or parties to sub - agreements.
C. In the event of violations of this code, officers, employees, or agents are subject to the following penalties
or disciplinary action:
1. Reprimand.
2. Suspension.
3. Termination of employment.
IV. Responsibilities
These standards shall not relieve the sponsor(s) of any contractual responsibilities under their contracts. The
institution is responsible, in accordance with good administrative practice and sound business judgment, for the
settlement of all contractual and administrative issues arising out of procurements entered into in support of the
program. These include, but are not limited to:
A. Contractual responsibilities /administrative issues:
1. Source evaluation.
2. Protests of award.
3. Disputes.
4. Claims.
B. Other responsibilities are as follows:
1. All proposed procurement actions shall be reviewed to avoid purchases of unnecessary or
duplicate items.
FORM SPI CNS 1136PS (Rev. 10/12)
4
OSPI /Child Nutrition Services
Attachment 4 to Bulletin No. 030 -13 CNS
August 2013
2. Procurement procedures shall not restrict or eliminate competition. Examples of restrictive
practices include, but are not limited to:
a. Placing unreasonable requirements on potential bidders' firms in order for them to qualify
for the contract award.
b. Noncompetitive practices between bidders.
c. Organizational conflicts of interest.
d. Unnecessary experience and bonding requirements.
3. Technical requirements for the material, product, or service to be procured shall be clearly and
accurately described. The description will not contain features that unduly restrict competition.
4. Contracts shall be awarded only to responsible contractors that possess the potential to perform
successfully under the terms and conditions of the proposed procurement. Consideration will be
given to contractor integrity, compliance with public policy, record of past performance, and
financial and technical resources.
5. The cost plus a percentage of cost method of contracting is prohibited.
V. Procurement Records
The following records shall be retained for each procurement:
A. Records sufficient to detail the significant history of a procurement shall be maintained for three years
from the end of the federal fiscal year to which these records pertain.
B. These records shall include, but are not necessarily limited to:
1. Information pertinent to the rationale for the method of procurement.
2. Selection of contract type.
3. Contractor selection or rejection.
4. The basis for the cost or price.
C. Recommended documentation:
1. The advertisement or public notice used to publicize the procurement or an affidavit of publication.
2. The solicitation letter forwarded to prospective vendors along with any replies received from
prospective vendors.
3. The IFB or RFP.
4. The proposed contract (completed by the vendor in response to IFB or RFP).
5. Any other information necessary to explain or justify the particular procurement method(s) utilized,
cost benefits determination, etc.
FORM SPI CNS 1136PS (Rev. 10/12)
5
OSPI /Child Nutrition Services
Attachment 4 to Bulletin No. 030 -13 CNS
August 2013
CERTIFICATION STATEMENT
I have read and understand my responsibilities as listed on these procurement standards. Our organization will adopt
these procurement standards for all purchases using USDA funds. Our organization understands that more restrictive
procurements may be re • ui ed by state law or adopted by our organization.
ignature of D;;r *ed Official or Owner(s)
RETURN ADDRESS:
e—c) —j_e3
Child Nutrition Services
Office of Superintendent of Public Instruction
PO Box 47200
Olympia, WA 98504 -7200
FORM SPI CNS 1136PS (Rev. 10/12)
6
OSPI /Child Nutrition Services
Attachment 4 to Bulletin No. 030 -13 CNS
August 2013
SECTION A AGREEMENT
OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
Child Nutrition Services
Old CaP(tol Building, PO BOX 47200
OLYMPIA, WA 98504 -7200
Child and Adult Care Food Program
CHILD CARE CENTER AGREEMENT
12-039
Council Approval N/A
AGREEMENT NUMBER
J y l Jl- /7f
In order to carry out the purpose of Section 17 of the National School Lunch Act, as amended, and the regulations governing the
Child and Adult Care Food Program (CACFP) issued thereunder (7 CFR Part 226) (CFDA number 10.558) the Office of
Superintendent of Public Instruction (OSPI) (hereinafter referred to as the "state agency") and the institution whose name and
address appear below, agree as follows:
Legal Name of Institution 04 1 A w
y t
Physical Location I 2-Li U7 Ind R S ToLw4a WPli q F I LP} V 4p
Street City/State Zip Cade County
Mailing Address p
(if different) w VJ'4 q 0! V kto q
Street/PO BDx city Zip Code County J
The institution:
1. Accepts final administrative and financial responsibility for total CACFP operations at all centers for which a site application
has been submitted to and approved by the state agency.
2. Certifies that they are in compliance with all applicable state rules and regulations regarding governing boards of
corporation.
3. Certifies that neither the institution nor any of its principals has been convicted of any activity that occurred in the last seven years
that indicated a lack of business integrity including, but not limited to, fraud, antitrust violations, embezzlement, theft, forgery, bribery,
falsification or destruction of records, making false statements, receiving stolen property, making false claims, obstruction of justice,
or any other activity indicating a lack of business integrity as defined by the state agency.
4. Certifies that a complete set of reliable certification statements (FORM SPI 1576) is on file for each responsible principal in our
organization.
5. Certifies that in each proprietary center 25 percent of the children in care (enrolled or licensed capacity, whichever is less) are
eligible for free or reduced -price meals in the month preceding application to the program. The institution shall continue to certify
and provide such information in each succeeding month. The institution shall not claim reimbursement for meals served in any
proprietary center for any month during which the center does not meet the eligibility requirement. It also Certifies that all centers
under this agreement have the same legal identity.
6. Understands an interest charge at the current federal rate will be assessed on all customer debt if not paid within 30 days of
notification.
7. Assures that all children at the sites described on the application forms are served the same meals at no separate charge
regardless of race, color, national origin, gender, age, or disability, and there is no discrimination in the course of the food
service.
8. Certifies that the submission of false information to the state agency is grounds for termination or denial from the CACFP as
described in 7 CFR 226.6(c).
9. Understands and agrees that any publications by the institution may be freely copied by the state agency or by other
institutions under the CACFP.
10. Assures that all publications, posters, and informational materials provided to the public will include a statement that the
program is available to eligible children without regard to race, color, national origin, gender, age, or disability. The statement
will also include information that any person who believes that he or she has been discriminated against in any U.S.
Department of Agriculture (USDA) related activity should write immediately to the Secretary of Agriculture, Washington, DC
20250. Office pp of hh'' Superintendent
11. Will maintain daily records to include, at a minimum, a menu that meets CACFP meal pattern, daily M I,8RtL 5s W4
eligible children taken at the point of service, and attendance records. All records must be maintained for the past three
fiscal years plus the current year, or until resolution of any outstanding reviews or audits. MAY 0 8 2012
12. Agrees to complete the audit requirement as listed in Section B.
tv
FORM SPI CACFP 1269A (Rev. 9/11) Page 1 of 5 OSPI /Child NyR?!lyiQ'
Attach September 30 It o l�V nngtton
The institution (continued):
13. Assures the state agency that announced and /or unannounced reviews will be allowed during normal business hours by the state
agency and /or representatives of U.S. Department of Agriculture (USDA) Food and Nutrition Service and /or any other state or
federal official. Anyone making such reviews must show photo identification that demonstrates that they are employees of one of
these entitites.
14• Assures the state agency that it will be responsible for all overpayments.
15. Agrees to comply with collection procedures set forth by RCW 19.16.500. Collection of funds owed to OSPI as a result of an
overpayment of claims or an advance (or any other situation resulting in an overpayment) made to the institution by OSPI shall
comply with the following:
a) Venue. The venue of any action arising out of this agreement shall be in Thurston County, Washington.
b) Governing Law. This contract is entered into pursuant to and under the authority granted by the laws of the state of
Washington and any applicable federal laws. The provisions of this agreement shall be construed to conform to those
laws.
c) In the event collection efforts become necessary, the institution agrees that it is liable for all costs associated with such
collection activity including, but not limited to, court costs, attorney's fees, and allowable interest. If the amount owing is
referred to a licensed collection agency, a collection fee shall be assessed pursuant to RCW 19.16.500 in an amount up
to 50 percent of the first $100,000 and 35 percent for amounts over $100,000.
The collection procedure is binding on the applicant, its successors, transferees, and assignees as long as it receives
assistance or retains possession of any assistance from OSPI.
16. Understands if this application does, not meet all of the requirements in the Child and 'Adult Care Food Program regulations,
7 CFR 226.6(b) and 226.15(b) and 226.16(b), the state agency must deny the application. If the state agency determines that the
institution has committed one or more serious deficiencies in 226.6(c)(1)(ii) for new institutions or 226.6(c)(2)(ii) for renewing
institutions, the state agency must initiate action to deny the application and initiate action to disqualify the institution and the
responsible principals and responsible individuals.
17. Agrees that the CACFP is approved to operate until the agreement is terminated by either party. Agrees to notify OSPI immediately
in writing if the institution or any of its facilities move, change names, sell the center(s), and are no longer in business and indicate the
last day of meal service. This agreement is voided upon sale of the institution and its facilities.
The state agency and the institution mutually agree:
1. To comply with and meet all responsibilities and requirements set forth in 7 CFR Part 226, CACFP regulations incorporated herein
by reference.
2. This agreement remains in effect until terminated by either party, contingent upon the availability of program funds.
3. The institution will be reimbursed under the claiming percentage method.
4. The institutions) will be reimbursed at the free rate for all at -risk meals served at the "at -risk" site.
5. The nonprofit homeless shelter will be reimbursed at the free rate for all meals served.
6. That new institutions will submit a public media release.
7. Neither the institution nor any employee or agent of the institution shall participate in the performance of any duty or service in
whole or part under this contract in violation of, or in a manner that violates, any provision of the Ethics in Public Service law at
chapter 42.52 RCW, or RCW 42.17.130 and 41.06.250 prohibiting the use of public resources for political purposes.
8. Each party,tp this agreement hereby assumes responsibility for claims and /or damages to persons and /or property resulting from 11
any act or omission on the part of itself, its employees, its officers, and its agents. Neither party assumes any responsibility to the
other patty for the consequences of any claim, act, or omission of any person, agency, firm, or corporation not a party to this
agreement.
9. No person shall, on the ground of race, color, national origin, gender, age, or disability, be excluded from participation in, be
denied the benefits of, or be otherwise subjected to discrimination under any activity performed under this agreement.
Nondiscrimination laws applicable to the state agency and sponsor that each party agrees to abide by include, but are not limited
to, the federal Americans with Disabilities Act (ADA). The institution shall notify the state agency immediately of any allegations,
claims, disputes, or challenges made against it under the ADA.
FORM SPI CACFP 1269A (Rev. 9/11) Page 2 of 5 OSPI /Child Nutrition Services
Attachment 3 to Bulletin No. 057 -11 CNS
September 30, 2011
The institution with an "at- risk" center agrees to follow all provisions at 7 CFR 226.17a, including:
1. To serve at -risk meals to students at sites in geographic areas where at least 50 percent of all students are certified eligible
for free or reduced -price meals at no charge.
2. To claim a maximum of one at -risk snack and meal per student per day only after his /her school day has ended.
3. To claim a maximum of one at -risk snack and meal per student in attendance any time of the day on weekends or holidays,
including vacation periods, during the regular school year.
4. To maintain attendance records.
The institution with a homeless shelter(s) agrees:
1. To provide proof that all homeless shelters are in compliance with all applicable state and /or local health and safety
standards as found in Rules and Regulations of the State Board of Health for Food Service, WAC 246 -215.
2. To provide congregate meal service and meals at no separate charge.
3. To maintain attendance records indicating the names and ages of children in residence for whom meals are claimed.
4. To maintain records of the number of meals by type (breakfast, lunch, supper, and snacks) served to eligible residential
children. The institution shall not claim more than three (3) meals (breakfast, lunch, supper) or two (2) meals and one (1)
snack or two (2) snacks and one (1) meal for any child in attendance during the designated meal times.
NOTE: No moneys or other benefits may be paid out under this program unless this agreement is completed and
approved (7 CFR 226).
SECTION B AUDIT REQUIREMENTS
Audit requirements for institutions (subrecipients) expending federal funds from state agency under this contract are
as follows:
The institution shall make their records available for review or audit by officials of the state agency or designee.
If the institution is a state, local government, or nonprofit subrecipient of federal awards and meets or exceeds the expenditure
threshold as stated in Office of Management and Budget (OMB) Circular A -133, they shall comply with the requirements of that
circular.
OMB Circular A -133 requires the institution to procure, at their expense, a single or program specific audit for any year in which
they meet or exceed the federal expenditure threshold. The institution shall incorporate OMB Circular A -133 audit requirements
into all contracts between the institution and its subcontractors who fall under the definition of subrecipients. The institution shall
comply with any future amendments to OMB Circular A -133 and any successor or replacement circular or regulation.
Upon completion of each audit, the institution shall submit the published audit report to OSPI, Attn: Child Nutrition Services,
PO Box 47200, Olympia WA 98504 -7200. OMB Circular A -133 audit reports are due within the earlier of 30 days after receiving
the audit report or nine months after the institution's fiscal year end. If such audit report contains audit findings that could have
an impact on the administration of program funds received through this office, the institution may be subject to requirements of
WAC 392 -115 regarding resolution of those findings.
It is the institution's responsibility to ensure that all audits required by OMB Circular A -133 are submii "&t�ff §"It'Wbent
Clearinghouse. If an extension of time has been granted by the institution's cognizant or oversight agen5y,rygffy 0 I 1p#t�r
granting the extension must be sent to OSPI.
MAY 08 Z
Child Nutrition Servicos
State of Washington
FORM SPI CACFP 1269A (Rev. 9/11) Page 3 of 5 OSPI /Child Nutrition Services
Attachment 3 to Bulletin No. 057 -11 CNS
September 30, 2011
The state agency has the discretion to call for audits beyond those required by law. The state agency sets audit policy for audits of
proprietary institutions that administer child nutrition programs and may order an audit of a proprietary institution based on risk
assessment.
SECTION C NONDISCRIMINATION STATEMENT
The institution:
HEREBY AGREES THAT it will comply with Title VI of the Civil Rights Act of 1964 and all requirements imposed by the regulations of
the Department of Agriculture (7 CFR Part 15), Department of Justice (28 CFR Parts 42 50), Title IX of the Education Amendments
of 1972, Section 504 of the Rehabilitation Act of 1973, the Age of Discrimination Act of 1975, and Food and Nutrition Service (FNS)
directives or regulations issued pursuant to that act and the regulations to the effect that no person in the United States shall, on the
grounds of race, color, national origin, gender, age, or disability, be excluded from participation in, or be denied the benefits of, or be
otherwise subject to discrimination under any program or activity for which the applicant received federal financial assistance from
the department; and HEREBY GIVES ASSURANCE THAT it will immediately take any measures necessary to effectuate this
agreement.
THIS ASSURANCE IS given in consideration of and for the purpose of obtaining any and all federal financial assistance, grants and
loans of federal funds, reimbursable expenditures, grant or donation of federal property and interest in property, the detail of federal
personnel, the sale and lease of, and the permission to use, federal property of interest in such property or the furnishing of services
without consideration or at a nominal consideration, or at a consideration which is reduced for the purpose of assisting the recipient,
or in recognition of the public interest to be served by such sale, lease, or furnishing of services to the recipient, or any improvements
made with federal financial assistance extended to the applicant by the state agency. This includes any federal agreement,
arrangement, or other contract which has as one of its purposes the provision of assistance such as food, Washington Basic Foods,
cash assistance for the purchase of food, and any other financial assistance extended in reliance on the representations and
agreements made in this assurance.
BY ACCEPTING THIS ASSURANCE, the applicant agrees to compile data, maintain records, and submit reports as required, to
permit effective enforcement of Title VI and permit authorized USDA and state agency personnel during normal working hours to
review such records, books, and accounts as needed to ascertain compliance with Title VI. If there are any violations of this
assurance, the Department of Agriculture, FNS, shall have the right to seek judicial enforcement of this assurance.
This assurance is binding on the applicant, its successors, transferees, and assignees as long as it receives assistance or retains
possession of any assistance from the state agency. The person or persons whose signatures appear below are authorized to sign
this assurance on behalf of the applicant.
SECTION D FRAUD
Whoever embezzles, willfully misapplies, steals, or obtains by fraud any funds, assets, or property that are subject of a grant or
other form of assistance under 7 CFR 226.25(e), whether received directly or indirectly from the state agency or the USDA or
whoever receives, conceals, retains such funds, assets, or property to his /her use or gain, knowing such funds, assets, or property
have been embezzled, willfully misapplied, stolen, or obtained by fraud shall, if such funds, assets, or property are of the value of
$100 or more, shall be fined not more than $10,000 or imprisoned for not more than five years or both.
FORM SPI CACFP 1269A (Rev. 9/11) Page 4 of 5 OSPI /Child Nutrition Services
Attachment 3 to Bulletin No. 057 -11 CNS
September 30, 2011
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"'lea., .i�l.i''.;�i�Yrt S�' 1
I hereby certify that the organization will abide by our management plan, budget, and all applicable state and federal regulations
and policies will be observed. I hereby certify that the information on this application and the required attachments are true to the
best of my knowledge; that reimbursement will be claimed only for meals served to eligible children; and that the CACFP will be
available to all eligible children regardless of race, color, national origin, gender, age, or disability at the approved food service
facility and that these facilities have the capability for the meal service planned for the number of children anticipated to be served.
I understand that this information is being given in connection with the receipt of federal funds, that representatives of the USDA
and the state agency may verify this information, and that deliberate misrepresentation may subject me to prosecution under
applicable state and federal criminal statutes. I understand that institutions and individuals providing false certification will also be
placed on the national disqualified list.
Debarment, Suspension, and Ineligibility. Institution certifies that neither it nor its principals are debarred, suspended, proposed
for debarment, or voluntarily excluded from participation in transactions by any federal department or agency. The institution
further certifies that they will ensure that potential subcontractors or subrecipients or any of their principals are not debarred,
suspended, proposed for debarment, or voluntarily excluded from participation in "covered transactions" by any federal department
or agency. "Covered transactions" include procurement contracts for goods or services awarded under a nonprocurement
transaction (e.g., grant or cooperative agreement) that are expected to equal or exceed $25,000, and subawards to subrecipients
for any amount. Contractor may do so by obtaining a certification statement from the potential subcontractor or subrecipient or by
checking the "List of Parties Excluded from Federal Procurement and Non Procurement Programs" provided on -line by the General
Services Administration.
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Sign r /Owner(s)
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Mailina Address
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Date of Birth: r
Printed Name of Board Chairperson/Board Member and Title /President of Corporation
Signature of Board Chairperson/President of Corporation
Mailing Address
Date of Birth:
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SIGNA RE
Date
�r,�+�w► l a fnl U 8te
City, State, Zip Code
Date
City, State, Zip Code
Director. Child Nutrition Services
APPROVALDATE
OffiC of 1 qI1per 4 ptQpd;j p1
of Publir lns- rn
MAY 08 ?,012
Child Nutrition Serv,c ,wa
State of Washington
FORM SPI CACFP 1269A (Rev. 9/11)
Page 5 of 5
OSPI /Child Nutrition Services
Attachment 3 to Bulletin No. 057 -11 CNS
September 30, 2011
r Office of Superintendent of Public Instruction
Child Nutrition Services
Child and Adult Care Food Program
Child Care Institutions
CAC FP NEW INSTITUTION PACKET CHECKLIST
Building for Fiscal Year 2012
the Future
E Food Chart (one per site)
c� WIC flyer in 3 languages provide this information to all parents /guardians by
either posting or distributing in another way. Additional languages are available
at httD: /www.withinreachwa.ora /download materials
Building for the Future flyer in 3 languages provide this information to all
parents /guardians by either posting or distributing in another way. Additional
languages are available at
htta: /www. fns. usda .aov /cnd /care /Translations /Meal Benefit Form Translations
htm
Requirements for Civil Rights Compliance
Building for the Future poster
"And Justice For All" poster display where parents /guardians can readily see
it.
Bulletin No. 080 -08 —Child and Adult Care Food Program Administrative Review
Procedures: Definitions, Purpose, Procedure, Procedure Special Conditions
E Regulations (7 CFR 226)
Washington State Child and Adult Care Food Program Center Manual is
available online at (currently under revision):
htta: /www.kl 2. wa. us/ ChildNutrition /CACFPmanual.aspx
Job Descriptions -Head Cook and Center Director or Sponsor
USDA Recipes for Child Care is available online at:
htti3:// www. nfsmi .ora /Resource0verview.asDx ?ID =114
MyPlate posters can be ordered online at: htta: /tn.ntis.aov/
If any of the above items are missing, please call Adele Roberts at 360- 725 -6200.
Office of Superintendent of Public Instruction
Child Nutrition Services
INSTRUCTIONS
Complete and return to Child Nutrition Services (CNS). E -mail addresses are required for each person unless a waiver is requested.
Keep a copy for your files.
The designated official who signed the Agreement must authorize the submission of claims or access to the application by the staff
members who have signed the certification below. Unless the designated official is listed as an authorized user, he /she will not have
access to the secured Web site.
Changes in any of the authorized signer(s) of claims or individuals with access to the application must be submitted to CNS on this
form. The designated official who signed the Agreement must sign on the appropriate line below.
CERTIFICATION
I understand that the use of the user name and password to access the CNS Web site is equivalent to an original signature for
purposes of official documentation. I understand that someone else using my user name and password is equivalent to them forging
my signature.
By using the user name and password, I certify the information transmitted is complete and accurate per federal regulation
7 CFR 226.
I accept responsibility to maintain the integrity of the user name and password. If the user name and password is assigned to another
individual, I understand I will be responsible for the content of the information transmitted to CNS.
If I believe my user name and password have been compromised, I will notify CNS immediately and be assigned a new password.
If the ultimate responsibility for submitting claims or application information is no longer my responsibility, I will notify OSPI to terminate
access.
My signature indicates I have read the agreement and am aware of the conditions and responsibilities expressed.
Designated employees assigned responsibility for the application or claims:
PRINT NAME AND TITLE i
SIGNAT rE V
1 A "Ib rl�m
PRINT M Af !D ITLE
SIGNATURE U
T
PRINT NAME AND TITLE
SIGNATURE
Assigned Responsibility V-j Application
Claims
E- MAILADDRESS G
Assigned Responsibility Application
Claims
mi w kW't1a+,a..
E -MAIL ADDRESS J U
E -MAIL ADDRESS
Assigned Responsibility Fl Application
E] Claims
I HEREBY AUTHORIZE THE INDIVIDUALS LISTED ABOVE TO SUBMIT APPLICATION INFORMATION AND /OR CLAIMS
ELECTRONICALLY. THE DESIGNATED OFFICIAL (INDIVIDUAL WHO SIGNED THE AGREEMENT) MUST COMPLETE THIS
FORM.
Institution Name /_W1 (A
Signature of Designated Official
Printed Name of Designated Official
fA
i
nhxdAl
Phone Number 23Gl�3- Lo S Z- 2—
LJ Date.1 9. 1 Z J
Title O�GGY�.�j�1 Sant ✓lNf
OSPI /Child Nutrition Services
Attachment 4 to Bulletin No. 057 -11 CNS
September 30, 2011
FORM SPI CACFP 1136 AUTH SIG (Rev. 8/10)
OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION OSPI AGREEMENT NUMBER
Child Nutrition Services i
pF PUg
Old Capitol Building, PO BOX 47200 I
OLYMPIA WA 98504 -7200
w boy
Child and Adult Care Food Program
USER AUTHORIZATION
INSTRUCTIONS
Complete and return to Child Nutrition Services (CNS). E -mail addresses are required for each person unless a waiver is requested.
Keep a copy for your files.
The designated official who signed the Agreement must authorize the submission of claims or access to the application by the staff
members who have signed the certification below. Unless the designated official is listed as an authorized user, he /she will not have
access to the secured Web site.
Changes in any of the authorized signer(s) of claims or individuals with access to the application must be submitted to CNS on this
form. The designated official who signed the Agreement must sign on the appropriate line below.
CERTIFICATION
I understand that the use of the user name and password to access the CNS Web site is equivalent to an original signature for
purposes of official documentation. I understand that someone else using my user name and password is equivalent to them forging
my signature.
By using the user name and password, I certify the information transmitted is complete and accurate per federal regulation
7 CFR 226.
I accept responsibility to maintain the integrity of the user name and password. If the user name and password is assigned to another
individual, I understand I will be responsible for the content of the information transmitted to CNS.
If I believe my user name and password have been compromised, I will notify CNS immediately and be assigned a new password.
If the ultimate responsibility for submitting claims or application information is no longer my responsibility, I will notify OSPI to terminate
access.
My signature indicates I have read the agreement and am aware of the conditions and responsibilities expressed.
Designated employees assigned responsibility for the application or claims:
PRINT NAME AND TITLE i
SIGNAT rE V
1 A "Ib rl�m
PRINT M Af !D ITLE
SIGNATURE U
T
PRINT NAME AND TITLE
SIGNATURE
Assigned Responsibility V-j Application
Claims
E- MAILADDRESS G
Assigned Responsibility Application
Claims
mi w kW't1a+,a..
E -MAIL ADDRESS J U
E -MAIL ADDRESS
Assigned Responsibility Fl Application
E] Claims
I HEREBY AUTHORIZE THE INDIVIDUALS LISTED ABOVE TO SUBMIT APPLICATION INFORMATION AND /OR CLAIMS
ELECTRONICALLY. THE DESIGNATED OFFICIAL (INDIVIDUAL WHO SIGNED THE AGREEMENT) MUST COMPLETE THIS
FORM.
Institution Name /_W1 (A
Signature of Designated Official
Printed Name of Designated Official
fA
i
nhxdAl
Phone Number 23Gl�3- Lo S Z- 2—
LJ Date.1 9. 1 Z J
Title O�GGY�.�j�1 Sant ✓lNf
OSPI /Child Nutrition Services
Attachment 4 to Bulletin No. 057 -11 CNS
September 30, 2011
FORM SPI CACFP 1136 AUTH SIG (Rev. 8/10)
pF Pr/g�
0
OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
Child Nutrition Services
Old Capitol Building, PO BOX 47200
Olympia, WA 98504 -7200
Child and Adult Care Food Program
SPONSOR INFORMATION
SPONSOR APPLICATION
SPONSOR NAME AGREEMENT NUMBER FEDERAL ID NUMBER DUNS NUMBER PROGRAM YEAR
a
ADDRESS INFORMATION
ADDRESS Z4 L4 2 P, d ft.eS I ADDRESS
ADDRESS (Cont.) I ADDRESS (font.)
CITY F 9 K `1 q c j 1 I (D I CITY
STATE F
f11% ZIP CODE STATE ZIP CODE
COUNTY COUNTY
.,n':.'�'�n$�a�k.1�`?aa. :v s.<,. ��'��`s5.z. y.:., ..d F'1 E?m.$ v' a.:'� >'s�'
ADDRESS I
ADDRESS (Cont.)
CITY
STATE
COUNTY
ZIP CODE
The street address is the same as the mailing address.
PAYMENT INFORMATION
ADDRESS
1242? �V2�
ADDRESS (Cont.)
CITY 4 L) V'Llo it
STATE w �•1
COUNTY Vj
The payment address is the same as the mailing address.
FORM SPI CACFP 1269SI (Rev. 1/11)
ZIP CODE l'+,r M 6
OSPI /Child Nutrition Services
Page 1 Attachment 5 to Bulletin No. 057 -11 CNS
September 30, 2011
Appl' do Type
Child Care Center Adult Care Center Day Care Home
Organization Type
Q Profit Nonprofit
Vendor Type
Private business
Government
Ownership Code
Sole Owner
M\1 Government
Out -of -State Corporation
Sponsor Type
Administrative Sponsor
Center Sponsor
For Centers Only:
Number of approved facilities
Public
Other
Partnership
Washington Corporation
(Inc. or other than LLC)
LLC (Limited Liability Company)
Independent Center
Day Care Home Sponsor
CONTACTS
NAME (First, Mid Is, Last)
�l I Yl L -\/v1 Yl�
PHONE (e.g. (555) 555 -5555, extension) ,f EXT TITLE
Zt�IP tv 7 Z bK.1 Y �eeA CF�>uV Gt f Y�
FAX Lv 7 (o t. fo �iy' I E -MAIL Kul Vto0 s�MCUA i� V
ADDRESS DATE OF BI
1 2, 4 -4 y 2,r'A l�.e s 30
cIT COUNTY
STATE w p I ZIP CODE LIP l e)
NAME (First, Middle, Last)
PHONE (e.g. (555) 555 -5555, wdension)
FAX
ADDRESS
CITY
STATE
T EXT (TITLE
E -MAIL
DATE OF BIRTH
(COUNTY
ZIP CODE
M The claim contact is the same as the program contact.
yy
FORM SPI CACFP 1269SI (Rev. 1/11)
OSPI /Child Nutrition Services
Page 2 Attachment 5 to Bulletin No. 057 -11 CNS
September 30, 2011
ON
NAME (First, Middle, Last)
PHONE (e.g. (555) 555-5555, extension)
FAX
ADDRESS
CITY
STATE
T EXT TITLE
E -MAIL
DATE OF BIRTH
COUNTY
ZIP CODE
E] The owner, president, or CEO contact is the same as the program contact.
Yes No
Requesting Advances? Amount Requested
Requesting Expansion Funds?
F1 Requesting Start Up Funds?
Method of reimbursement for Tier I I Mixed rate providers
R Actual
F] Blended
F] R Percentage
Tier 1 I Tier 11 High Tier 11 Low Tier 11 Mixed I Total
Number of family day care home
providers
Number of children
OSPI/Child Nutrition Services
FORM SPI CACFP 1269SI (Rev. 1/11) Page 3 Attachment 5 to Bulletin No. 057-11 CNS
September 30, 2011
'M
NAM�6�01 L Q fi
PHONE (e.g. (555) 555-5555, extension)
EXT
TITLE,
Pitcreo--ii
C)02-4
1 E-MAIL
'U IV
AE RESS
L1 42)ld
DATE OFBIRTH `,p
2--16
CITY 1 W,
COUNTY 0�
STATE LKA
ZIP CODE 9 gf(v P,
ON
NAME (First, Middle, Last)
PHONE (e.g. (555) 555-5555, extension)
FAX
ADDRESS
CITY
STATE
T EXT TITLE
E -MAIL
DATE OF BIRTH
COUNTY
ZIP CODE
E] The owner, president, or CEO contact is the same as the program contact.
Yes No
Requesting Advances? Amount Requested
Requesting Expansion Funds?
F1 Requesting Start Up Funds?
Method of reimbursement for Tier I I Mixed rate providers
R Actual
F] Blended
F] R Percentage
Tier 1 I Tier 11 High Tier 11 Low Tier 11 Mixed I Total
Number of family day care home
providers
Number of children
OSPI/Child Nutrition Services
FORM SPI CACFP 1269SI (Rev. 1/11) Page 3 Attachment 5 to Bulletin No. 057-11 CNS
September 30, 2011
Yes No
Do you charge separately for meals?
51 Does institution operate in other states? if so, under what names?
r Has the institution, or any of its principals, been declared ineligible to participate in the CACFP for violating
CACFP program requirements and is on the National Disqualified List? If yes, explain.
Has the institution, or any of its principals been declared ineligible to participate in any other publicly- funded
program? If yes, explain.
3 9 Institution attended training. Date: 12-
Provide the breakdown of enrollment by ethnic and racial category
American Indian Native Hawaiian Black or
or Alaskan Native Asian or Other Pacific African Hispanic or White Multi Racial Total
Islander American Latino
Yes No
Does the institution and all facilities /sites accept all participants regardless of race, color, age, gender, disability,
or national origin?
M\/ Has the institution ever been found to be in noncompliance of the civil rights laws by any federal agency?
ro 2 :r S" X �5 {.R&�'°'.��� x 3 .fi �3�• y '$•y� �'k'"� �hss'� g
d K
Oct Nov
Dec
Jan Feb Mar
E3
Apr May Jun Jul Aug Sept All Mont s
FORM SPI CACFP 1269SI (Rev. 1/11) Page 4 OSPI /Child Nutrition Services
Attachment 5 to Bulletin No. 057 -11 CNS
September 30, 2011
Note: Public school districts, educational service districts, public universities and colleges, cities, counties, other municipalities,
for profits and federal government agencies are exempt from completing this section. Please indicate if this includes your
organization by checking the box marked not applicable (n /a). Tribal organizations must complete this section. VZn /a
Enter the institutions most recently completed fiscal year -end (e.g., 7/01/2007 through 06/30/2008, enter 06/30/2008).
Month I 12— I Day 1 31 1 Year I 2C) i I
Enter the total amount of federal funds expended during the most recently completed fiscal year, as stated above. Include all
federal funds regardless of the source. (e.g., HHS, USDA, HUD, etc.)
Federal regulations require that audits of nonprofit institutions including tribal organizations are to be conducted in accordance with
Office of Management and Budget (OMB) Circular A -133.
If your total amount of federal funds expended is $500,000 or more:
You must submit a copy of your most recent OMB Circular A -133 audit report to:
Office of Superintendent of Public Instruction
Attn: Child Nutrition Services
PO Box 47200
Olympia, WA 98504 -7200
OSPI /Child Nutrition Services
FORM SPI CACFP 1269SI (Rev. 1/11) Page 5 Attachment 5 to Bulletin No. 057 -11 CNS
September 30, 2011
(This form must be completed for each center.)
1 f)L k R
SPONS NAME SITE NUMBER AGREEMENT NUMBER PROGRAM YEAR
1, OVAA-A
SITE NAME j COUNTY
ADDRESS 1
12.L4 4
CITY STATE ZIP
SITE CONTACT NAME (First, Middle, Last) PHONE FAX
�i VSb Zoe 1 lD 7 23 5 1 ?min `T doh Dc�2- I
TITLE E -MAIL
���tA 'I'l Iee.E'1 C�0►rd i oct+c- tr' 0,4"1I0-I)Q
NMI OWN
Check all that apply.
Adult Care Center Child Care
ff Child Care Center F� Head Start
Outside School Hours
ECEAP
At -Risk
Emergency Shelter
Number of Free Total
Organization Type Profit Nonprofit and Reduced Price: Enrolled: u)
x.. 5 a x r'" src�,x'sy .a
INDICATE METHOD BY WHICH MEALS WILL BE PROVIDED:
a. Preparation at meal service location (on site)
b. Preparation at central kitchen and transported
c. Under contract with local school system
d. Under contract with food service management
company*
EJ e. Vendor cost will exceed $100,000 (refer to OSPI
procurement standards)
*Contract form must be signed by sponsor and vendor
R Vendor /School Name
as wk'; I
SCHOOL DISTRICT
Schooi Year Beginning Date W 201,
QUALIFYING PUBLIC SCHOOL NAME G�StP�tt'� h SC�I.ty 1 �►►Gwc �l j 2.01 L
TO9 W> Itk ��>�y Le gem t yt School Year Ending Date
Does the Next School Year Begin Before October 1 st7 1 71 Yes 1:1 No If yes, please provide Next School Y r' Be at 1
Activities: M Educational F1 Enrichment
we na-vz Ctat I ci ry,c -u-
utA !_S f o e C(,- da-41 4 wo
Describe Educational /Enrichment Activities: {644 oo tz -ems d&q k f L+e P lGrvt S
Q r Ct7+^r�ev'zr G 7) Ham/ CG �1% t I/b �f Ilt�k- q i °7 Gt Gulp G/ q S ketL
OSPI /Child Nutrition Services
FORM SPI CACFP 1269S -APP (Rev. 9/11) Page 1 Attachment 6 to Bulletin No. 057 -11 CNS
September 30, 2011
OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
oa P[Ig
Child Nutrition Services
Old Capitol Building, PO BOX 47200
OLYMPIA WA 98504 -7200
22O 1ZN
C
Child Adult Care Food Program
and
CENTER APPLICATION
(This form must be completed for each center.)
1 f)L k R
SPONS NAME SITE NUMBER AGREEMENT NUMBER PROGRAM YEAR
1, OVAA-A
SITE NAME j COUNTY
ADDRESS 1
12.L4 4
CITY STATE ZIP
SITE CONTACT NAME (First, Middle, Last) PHONE FAX
�i VSb Zoe 1 lD 7 23 5 1 ?min `T doh Dc�2- I
TITLE E -MAIL
���tA 'I'l Iee.E'1 C�0►rd i oct+c- tr' 0,4"1I0-I)Q
NMI OWN
Check all that apply.
Adult Care Center Child Care
ff Child Care Center F� Head Start
Outside School Hours
ECEAP
At -Risk
Emergency Shelter
Number of Free Total
Organization Type Profit Nonprofit and Reduced Price: Enrolled: u)
x.. 5 a x r'" src�,x'sy .a
INDICATE METHOD BY WHICH MEALS WILL BE PROVIDED:
a. Preparation at meal service location (on site)
b. Preparation at central kitchen and transported
c. Under contract with local school system
d. Under contract with food service management
company*
EJ e. Vendor cost will exceed $100,000 (refer to OSPI
procurement standards)
*Contract form must be signed by sponsor and vendor
R Vendor /School Name
as wk'; I
SCHOOL DISTRICT
Schooi Year Beginning Date W 201,
QUALIFYING PUBLIC SCHOOL NAME G�StP�tt'� h SC�I.ty 1 �►►Gwc �l j 2.01 L
TO9 W> Itk ��>�y Le gem t yt School Year Ending Date
Does the Next School Year Begin Before October 1 st7 1 71 Yes 1:1 No If yes, please provide Next School Y r' Be at 1
Activities: M Educational F1 Enrichment
we na-vz Ctat I ci ry,c -u-
utA !_S f o e C(,- da-41 4 wo
Describe Educational /Enrichment Activities: {644 oo tz -ems d&q k f L+e P lGrvt S
Q r Ct7+^r�ev'zr G 7) Ham/ CG �1% t I/b �f Ilt�k- q i °7 Gt Gulp G/ q S ketL
OSPI /Child Nutrition Services
FORM SPI CACFP 1269S -APP (Rev. 9/11) Page 1 Attachment 6 to Bulletin No. 057 -11 CNS
September 30, 2011
Yes No
E Are infants (under 1 year of age) enrolled?
El M Is the site claiming infants (under 1 year of age)?
Yes No
Will this adult center limit its reimbursement to meals served only to enrolled participants who remain in the community
and reside with family members or other caregivers who would benefit from the respite which adult care service could
provide?
El El Does this adult center offer a structured, comprehensive program that provides a variety of health, social, and related
x �,fx� r •nit v
At -risk, emergency shelters, and outside school hour centers.
Yes No I have enclosed a current safety/sanitation inspection. es No I have enclosed a current fire /building inspection.
o Expiration date: Z Expiration date: s44/1
f I ASii4G
Send a co of current licen
py se.
Oct
support services to enrolled adult participants?
El El
Jan
Does this adult center have approval to provide day care services to functionally impaired adults in a group setting
Feb
E]
outside their home on a less than 24 -hour basis?
May
License Capacity
Does this center serve adults over 60 years of age?
0
EJ
Does this center serve functionally impaired adults over 60 years of age?
E Does
El Jun
this center serve functionally impaired adults under 60 years of age?
Jul Aug
Ej Sep
Does this center have individual plans of care for all functionally impaired adults who are enrolled and participating in
the Child and Adult Care Food Program?
0
EJ
Does this center receive reimbursement under Title III of the Older Americans Act?
E]
F]
Does this center receive reimbursement from the Child and Adult Care Food Program and funding from Title III for
the same meals?
x �,fx� r •nit v
At -risk, emergency shelters, and outside school hour centers.
Yes No I have enclosed a current safety/sanitation inspection. es No I have enclosed a current fire /building inspection.
o Expiration date: Z Expiration date: s44/1
f I ASii4G
Send a co of current licen
py se.
Oct
R
Nov Dec
Jan
Expiration Date
Feb
E]
Mar Ej Apr
May
License Capacity
El Jun
Jul Aug
Ej Sep
License Number
Ages of children on license from: to:
All Months
This center will open at: J D Ct rV 1 And will close at: �(j DID PIY)
Yes No Closed two or more weeks? �v
0 If yes, list closing dates and reopening dates:
11 Do you serve meals in shifts?
0 24 hour care
FORM SPI CACFP 1269S -APP (Rev. 9/11) Page 2 OSPI /Child Nutrition Services
Attachment 6 to Bulletin No. 057 -11 CNS
September 30, 2011
r MEAL SERVG INF
Meal Service
Meals Served (Excluding Eme
Begin
Breakfast I
A.M. Snack
Lunch
P.M. Snack I
Supper I e
Night Snack I
Information Emergency Shelter Meals
rgency Shelter) Meal Service Information
End Begin End
1I I I
I
it •r. k �v
A7 R[SK�)VIEALS
At -Risk
Meals Served School Days
Begin I End
At -Risk Breakfast
At -Risk A.M. Snack
At -Risk
Non School Days
Begin I End
At -Risk Lunch
At -Risk P.M. Snack �j' J vyk I (DU P 3 D0 PM
At -Risk Supper
At -Risk Night Snack
Start and stop times of meal service must be in 15 minute increments and must start on the quarter hours.
Sun Mon Tue Wed Thu Fri Sat
Check the days the site operates the CACFP El
Mon -Fri Q
OSPI /Child Nutrition Services
FORM SPI CACFP 1269S -APP (Rev. 9/11) Page 3 Attachment 6 to Bulletin No. 057 -11 CNS
September 30, 2011
All institutions must complete this annual budget.
REVENUE
CACFP revenue (estimate)
All other revenue from other sources (tuition, grants, DSHS, Medicaid, etc.)
Total Projected Annual Revenue
EXPENSES FOOD SERVICE OPERATIONS
Food purchases
Food service labor
Nonfood supplies— nonfood items needed to
support meal service (napkins, straws,
dishwashing detergent, etc.)
Other (specify)
Total Projected Food Service Operating Expenses
EXPENSES ALL OTHER COSTS
Labor
Supplies
Transportation
Rent and maintenance
Utilities (unless included with rent)
Other (specify)
Total Projected Annual Administrative Expenses
AGREEMENT NUMBER
7 IID -4D
I rA L1 Y 7
coo
�Lp. '!V
I
s
Yes No We use CACFP meal reimbursement for administrative expenses. If yes, we understand that at least 85%
of the meal reimbursement must go toward the food service operating costs. We maintain supporting
documentation on file.
FORM SPI CACFP 12698 (Rev. 9/11)
OSPI /Child Nutrition Services
Attachment 7 to Bulletin No. 057 -11 CNS
September 30, 2011
OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
pa pug
�o
Child Nutrition Services
Old Capitol Building, PO BOX 47200
OLYMPIA, WA 98504 -7200
e y
Child And Adult Care Food Program
°w $o
BUDGET INFORMATION
All institutions must complete this annual budget.
REVENUE
CACFP revenue (estimate)
All other revenue from other sources (tuition, grants, DSHS, Medicaid, etc.)
Total Projected Annual Revenue
EXPENSES FOOD SERVICE OPERATIONS
Food purchases
Food service labor
Nonfood supplies— nonfood items needed to
support meal service (napkins, straws,
dishwashing detergent, etc.)
Other (specify)
Total Projected Food Service Operating Expenses
EXPENSES ALL OTHER COSTS
Labor
Supplies
Transportation
Rent and maintenance
Utilities (unless included with rent)
Other (specify)
Total Projected Annual Administrative Expenses
AGREEMENT NUMBER
7 IID -4D
I rA L1 Y 7
coo
�Lp. '!V
I
s
Yes No We use CACFP meal reimbursement for administrative expenses. If yes, we understand that at least 85%
of the meal reimbursement must go toward the food service operating costs. We maintain supporting
documentation on file.
FORM SPI CACFP 12698 (Rev. 9/11)
OSPI /Child Nutrition Services
Attachment 7 to Bulletin No. 057 -11 CNS
September 30, 2011
OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION AGREEMENT NUMBER
Child Nutrition Services
Old Capitol Building
PO BOX 47200
Olympia WA 98504 -7200
Child and Adult Care Food Program
MANAGEMENT PLAN
Instructions: All new institutions must complete and sign the management plan. Attach required supporting
documentation. Return one copy to the state agency and make one copy for your files. Renewing institutions should
complete this on -line.
PART I: FINANCIAL VIABILITY
Fiscal Resources and Financial History
1. What year was your organization established?
gcf 7 atf�
2. What funds will be used to pay an overclaim?
4 f
3. How does the institution assure that money is spent appropriately and only for CACFP expenses?
tj e.� �ccot.t.�tit t �'�Gf! C� v
YES NO
4. Does your organization currently participate in other federally funded programs?
If yes, please specify:
5. Has your organization ever been terminated from participation in any USDA Child Nutrition
Program? If yes, explain (program, dates, circumstances, etc.).
6. Has your organization ever been disqualified from participation in any other publicly- funded program
for violating that program's requirements within the last seven years? (Publicly- funded means any
program or grant funded by federal, state, or local government.)
7. Is the organization, board president, director, or other persons responsible for the management of
the program on the CACFP National Disqualified List? If yes, list who.
k7J 8. Has the institution or any of its principals been convicted of any crime during the past seven years
that indicated a lack of business integrity? If yes, list who and explain. A principal means any
individual who holds a management position within, or is an officer of, an institution or a sponsored
center, including all members of the institution's or sponsored center's board of directors. A lack of
business integrity includes but is not limited to fraud, antitrust violations, embezzlement, theft,
forgery, bribery, falsification or destruction of records, making false statements, receiving stolen
property, making false claims, obstruction of justice, or any other activity indicating a lack of
business integrity as defined by the state agency.
9. List the publicly funded programs (i.e., DSHS, Head Start, county grants) in which your organization and its
principals have participated in the last seven years .0---
10. If you are a nonprofit organization, attach a copy of the most recent IRS Form 990 filed by your organization.
If not available, explain. (Does not apply to proprietary centers, federal and public institutions such as schools,
universities, local government, and churches.)
FORM SPI 1269MP (Rev. 9/11) Page 1 OSPI /Child Nutrition Services
Attachment 8 to Bulletin No. 057 -11 CNS
September 30, 2011
PART II: ORGANIZATIONAL CAPABILITY
Staffing Plan
In the chart below, list the position that will perform required duties in the operation of the CACFP.
CACFP Duties I Position Responsible for Duty
Approve income applications:
Ensure enrollment forms are updated annually:
Verify accuracy of income application approval:
Develop enrollment roster:
Verify accuracy of enrollment roster:
Train staff conceminq CACFP:
Train new staff concerning CACFP:
Plan menus:
Check menus for meal component compliance:
Cooks meals:
Serves meals:
Cleans up after meal preparation:
Orders or shops for food:
Takes point of service meal count:
Keeps food and labor costs on file:
Compiles claim for reimbursement:
Follow -up on block claims:
RP c rnt imp a 6 a*1 Cmd-•
i
v �q
coardirl
Cr cwa> f e7 k)-r
1./ a-
Train site monitors: (sponsors of multiple sites) g
Monitor sites: (sponsors of multiple sites) d�
Follow up on required corrective action at sites: (sponsors
of multiple sites)
2. How many hours a month will be spent on administrative labor? (Administrative labor refers to staff
responsible for planning, monitoring, training, and record keeping.) 7 hrs
3. How many hours a month will be spent on operating labor? (Operat ing labor refers to staff members who
spend time with meal preparation, serving, and cleanup.) J0- 2 J'S
YES NO
X 4. Are CACFP duties included in employee job descriptions, as applicable?
If no, indicat d to th applicable employee job descriptions will be revised to include CACFP
duties:3
5. Our organization will have a medical statement on file for each child /adult who has a milk
allergy /intolerance or if not, we will not claim the meal.
FORM SPI 1269MP (Rev. 9/11) Page 2 OSPI /Child Nutrition Services
Attachment 8 to Bulletin No. 057 -11 CNS
September 30, 2011
Yts No
6. Our organization maintains the confidentiality of eligibility information concerning individual
households.
7. Describe the meal planning procedures to ensure adequate amounts of food items are purchased,
prepared, and served to participants to meet or exceed the USDA minimum portion requirements.
PART III: INTERNAL CONTROLS
A. Governing Board
YES NO
Does your organization have a governing board? If no, or if military or government you can skip
this section and go to next page.
In the chart below, list board member names, title, area of expertise brought to the board, mailing address, phone
number, and familial and /or business relationship to other board members.
Name of Board I Area of Expertise I Mailing Address I Phone Number I Relationship
Member and Title
p,
YES NO NA.
1. Does your organization's governing board have policies and procedures that are available to
the state agency upon request?
2. Describe the board's roles in approving fiscal actions, policy decisions, and other
administrative actions.
3. How often does the board meet?
FORM SPI 1269MP (Rev. 9/11) Page 3 OSPI /Child Nutrition Services
Attachment 8 to Bulletin No. 057 -11 CNS
September 30, 2011
B. Operations
I. Training
All sites must receive training a minimum of one time per year. Organizations must keep records from
each training session that include the agenda, date, location, and sign -in form with all participants'
signatures. It is recommended that training sessions be conducted by an experienced trainer or staff
member who recently attended a CACFP workshop or training session provided by the state agency.
Complete the chart below:
Topics to be Discussed I Trainer I Date
General program policies /requirements
Meal pattern
Meal planninq
Meal countinq
Income eligibility applications except for
at- risk/homeless
Purchasinq of food and non -food items
Record keeping
Reimbursement process
Sanitation and safety reauirements
Civil riqhts compliance
Review procedures
Nutrition
i d
Food Allerqies
Other:
I I
I I
YES NO
1. Our organization will ensure all appropriate staff attends state agency training.
2. Our organization will address on -going staff training needs, and communicate CACFP changes and
organization policies and procedures to all staff at all sites.
3. Prior to CACFP approval of a new site, our organization will train the new staff.
FORM SPI 1269MP (Rev. 9/11) Page 4 OSPI /Child Nutrition Services
Attachment 8 to Bulletin No. 057 -11 CNS
September 30, 2011
Monitoring (Applies only to sponsors of multiple sites.)
Sponsoring organizations must adhere to annual monitoring requirements. Each site must be visited
unannounced. Additionally, each site should have two visits per year during a meal service and no more
than six months can elapse between each review. Each sponsor must have an "appropriate number" of
monitoring staff. Sponsors of centers are required to have one FTE monitor for each 25 -150 centers.
Monitoring requirements are as follows:
Type of Center
Mandatory Review During
No. of Reviews
Per Year
3 times /year
Adult Care Center /Day Care Centers /Emergency First 4 weeks of operation
Shelters /Head Start, At -Risk Snack Sites, Outside
School -Hours Programs (school sites and non school
sites)
YES NO
0, Do you have multiple sites? If no, continue to next page.
Complete a proposed schedule of reviews for each site on the following CACFP Site Monitoring
Schedule and Log. You must keep completed monitor review forms on file at the central office for
review by the state agency and /or the USDA.
CACFP Site Monitoring Schedule and Log
Fiscal Year 20_ October 1 September 30
(Start date to Closing date)
Reviewer Site Name Scheduled Dates for Review
FORM SPI 1269MP (Rev. 9111) Page 5 OSPI /Child Nutrition Services
Attachment 8 to Bulletin No. 057 -11 CNS
September 30, 2011
YES NO
❑j 2. Our organization has 25 -150 facilities. If yes, complete the monitor staffing requirements below.
Monitoring Staffing Requirements for Sponsoring Organizations with 25 -150 More Facilities
Instructions: Sponsoring organizations with 25-150 facilities must document and meet the required staffing
ratios. Complete the table below, providing all the specified information. (A full time employee works a total of
2,080 hours per year.) Child Nutrition Services will analyze the data to ensure the required monitor staffing
ratio has been met. Detailed employee position descriptions that include the percentage of time devoted to
each job activity /duty, including monitoring related activities, must be maintained. Documentation that
substantiates all submitted information must be maintained on file.
Name Position Hours Days Total
Minus Non-
Minus CACFP
Net Yearly
Per Per Hours
CACFP
Non Monitoring
Hours Spent
Day Year Per
Hours per
Hours per Year
on CACFP
Year
Year
Monitoring
Monitoring Related Activities
Employee activities that may be counted as monitoring duties include:
a. Monitoring—All activities related to conducting on -site reviews, including planning and scheduling; pre
review preparation; travel; supervisory oversight of monitors and the monitoring functions; time spent in
the facility during the review; writing review reports; conducting follow -up reviews; and activities relating
to the serious deficiency process (issuance of notice, evaluation of corrective actions, appeal, and
termination).
b. Household contacts Conducting parent contacts /surveys to help determine the validity of a facility's
claims.
c. On -site and other training—All on -site training that occurs during a facility review, initial or subsequent
training of sponsor staff that relates to the monitoring function.
d. Technical assistance —if provided during a review.
YES NO
3. Our organization will use review averaging. If yes, describe your plan. (New institutions may not use
review averaging.)
4. Our organization will do preoperational visits to each proposed facility.
5. Our organization will verify menus and menu records, daily attendance, and meal counts observed
during the monitoring visit with the claim.
6. Our organization will ensure that facilities have a valid license.
7. Our organization will review the facilities records pertaining to block claiming.
8. Our organization will ensure each staff member with monitoring responsibilities is trained.
FORM SPI 1269MP (Rev. 9/11) Page 6 OSPI /Child Nutrition Services
Attachment 8 to Bulletin No. 057 -11 CNS
September 30, 2011
YES NO
9. Our organization will train staff in all facilities on the following areas each fiscal year: CACFP meal
pattern, meal counts, claim submission and review procedures, recordkeeping requirements,
reimbursement system, and civil rights training. Training must be appropriate to the level of staff
experience and duties.
10. Our organization has a written Outside Employment Policy. This policy restricts employees with
responsibilities and duties for the CACFP from obtaining outside employment within or outside of
this institution that interferes with the completion of those CACFP responsibilities. In addition, any
employment outside of the CACFP responsibilities and duties may not constitute a real or apparent
conflict of interest with the CACFP.
11. How is information for disallowances based on observations made during visits transferred to
claims processing?
12. If corrective action is necessary at a facility, how will you follow -up to ensure compliance?
III. Record Keeping
1. Location of CACFP records:
Central
Not
Type of Record Office
Site Applicable
Enrollment/Income eligibility statements I
I X I
Enrollment forms t
I X I
Records of meals and supplements
served
Monthly claim for reimbursement
y
worksheets
Claims for reimbursement I
I X I
Receipts /invoices of expenditures I
I X I
Menus and menu production records I
I X
Time -in and time -out records /roster/
Sign -in sheets
Completed site review forms I
I X I
Time certification documentation for labor I
I X I
2. Your organization must retain CACFP records for at least three years, plus the current year.
Indicate where prior years documents will be housed.
Records Location Records Address
(home, office, garage, rental unit, etc.) (address, city, state, zip, etc.)
►Z�w �s T Oc�tjila,w S
YES NO
y��1� 3. Our organization understands that if we no longer participate in the CACFP we must still maintain
records for three years plus the current year. If an audit is being conducted, we will maintain the
records as necessary.
FORM SPI 1269MP (Rev. 9/11) Page 7 OSPI /Child Nutrition Services
Attachment.8 to Bulletin No. 057 -11 CNS
September 30, 2011
YES NO N/A
^A] 4. Do you store records off site? If yes, you must provide the names and phone numbers of two
individuals with immediate access to the CACFP records.
Name I Phone Number
1.
2.
5. For At -Risk Meal Programs only: Do you take meal counts to ensure no more than one at -risk
meal and one at -risk snack per day is claimed for each participant in your at -risk meal program?
If no, please explain.
Jy( For Homeless Shelters only: Do you take meal count by name to ensure no more than three
meals or two meals and one snack or two snacks and one meal per day are claimed for each
participant in your shelter?
If no, please explain.
CERTIFICATION
I hereby certify the information provided in this management plan is true and correct and that the organization will
abide by this management plan.
Signer of Designate V Date
v
FORM SPI 1269MP (Rev. 9111) Page 8 OSPI /Child Nutrition Services
Attachment 8 to Bulletin No. 057 -11 CNS
September 30, 2011
OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION AGREEMENT NUMBER
Child Nutrition Services
Old Capitol Building, PO BOX 47200
c OLYMPIA, WA 98504 -7200
Child and Adult Care Food Program
�ti a• =ie a0
NONDISCRIMINATION AND MEDIA POLICY STATEMENT
1:0 LAA1 I a t f31MQ1 �'_Pe.nW_assures the Office of Superintendent of Public Instruction (OSPI) that:
Name of Institution
We will submit a public release to the information media serving the area from which the child care
institution draws attendance announcing the availability of meals at no separate charge to children in
attendance. The release will contain either or all weekly, monthly, or yearly income guidelines for both free
and reduced -price meals.
2. We will include a statement that the program is available to eligible children without regard to race, color,
national origin, gender, age, or disability on all publications, posters, and informational materials provided to
the public. The statement will also include the information that any person who believes that he or she has
been discriminated against in any U.S. Department of Agriculture (USDA) related activity should write
immediately to the Secretary of Agriculture, Washington, DC 20250.
We will retain a copy of the public release sent to the information media in our permanent files, indicating
names, addresses, and dates releases were mailed and send a copy to OSPI along with a copy of the
cover letter sent to the media.
Signat esignated Official
n I
P IL l Date
m 4q", —K t tA" cr o �ttikwd Lc�
Title '_j J
FORM SPI CACFP 1269MR (Rev. 7/06)
OSPI /Child Nutrition Services
Attachment 9 to Bulletin No. 057 -11 CNS
September 30, 2011
MEDIA RELEASE
Child Care Center Name
Street Address 12—q Zq q� S
City, WA Zip Code a LP P�
Sent To
i
Phone Number W `7t<O'K —7f3� 2Z
Center Contact Person i�1 ��1 G�•�ad,�
Please print the following media release as a free public service announcement.
TodayTJ1[.W Vk C,om WL"*L4 name of center) announced its sponsorship of the U.S.
Department of Agriculture (USDA) Child and Adult Care Food Program administered by the Office of
Superintendent of Public Instruction (OSPI). Meals will be made available to enrolled children at no separate
charge without regard to race, color, national origin, gender, age, or disability. Parental income determines the
amount of money OSPI will reimburse institutions to provide meals to enrolled children. The monthly
income eligibility guidelines listed below are used to determine the reimbursement from OSPI.
FAMILY SIZE
FREE
REDUCED -PRICE
1
1,180
$1,679
2
1,594
2,268
3
2,008
2,857
4
2,422
3,446
5
2,836
4,035
6
3,249
4,624
7
3,663
5,213
8
4,077
5,802
For each additional
family member add: +414 +589
Any person who believes that he or she has been discriminated against in any USDA related activity should write
immediately to the Secretary of Agriculture, Washington, DC 20250.
Meals will be provided at the sites listed below:
Child Care Center Name _1_l) V_AA. I.tJYVIi/l/1..l. -A. Ce_viTf'�
Street Address 2-� L4Z I j(_, J
City, WA Zip Code t J 1&kl ul k ck I VJN V (ok
Phone Number q�( t7 ((Q() G,kl 2
OSPI /Child Nutrition Services
FORM SPI CACFP 1269 SAMP (Rev. 9/11) Attachment 10 to Bulletin No. 057 -11 CNS
September 30, 2011
OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
Child Nutrition Services
01,V 8 Old Captiol Bullding, PO BOX 47200
Olympia, WA 96504 -7200
Yf
CERTIFICATION REGARDING LOBBYING
CHILD NUTRITION PROGRAMS
AGREEMENTNUMBER
Applicable to grants, subgrants, cooperative agreements, and contracts exceeding $100,000 in federal funds.
Submission of this certification is a prerequisite for making or entering into this transaction and is imposed by Section 1352,
Title 31, U.S. Code. This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Any person who fails to file the required certification shall be subject to a civil
penalty of not less than $10,000 and not more than $100,000 for each such failure.
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for
influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee
of Congress, or an employee of a member of Congress in connection with the awarding of a federal contract, the making of
a federal grant, the making of a federal loan, the entering into of a cooperative agreement, and the extension, continuation,
renewal, amendment, or modification of a federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress,
or an employee of a member of Congress in connection with this federal grant or cooperative agreement, the undersigned
shall complete and submit Standard Form -LLL, "Disclosure of Lobbying Activities," in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award documents for all covered
subawards exceeding $100,000 in federal funds at all appropriate tiers and that all subrecipients shall certify and disclose
accordingly.
Check here if the organization does not receive more than $100,000 in federal funds. Complete the
information below and return this form with your application.
Name /Address of Sponsor 12tJ 7-q Ll 2M Ave S
ToV of V CL uJR Cl I LV
W/ ykoo,
Signature 0.
Name/Title (YA-�r
c�
FORM SPI CNS 280 LOB (Rev. 9/11)
Child Nutrition Programs
Name FNS Grant/Cooperative Agreement
Date
OSPI /Child Nutrition Services
Attachment 11 to Bulletin No. 057 -11 CNS
September 30, 2011
4. Name and Address of Reporting Entity:
Prime Subawardee
Tier if known:
Congressional District, if known:
6. Federal Department/Agency:
5. If Reporting Entity in No. 4 is Subawardee, Enter Name and
Address of Prime:
Congressional District, if known:
7. Federal Program Name /Description:
CFDA Number, if applicable:
8. Federal Action Number, if known: 9. Award Amount, if known:
10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if
(if individual, last name, first name, middle initial): different from 10.a.)
(last name, first name, middle initial):
(Attach Continuation Sheet(s) SF -LLL,A If necessary)
11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply):
actual ❑planned a retainer
b. one -time fee
c. commission
12. Form of Payment (check all that apply): d. contingent fee
a cash e. deferred
f. other, specify:
b. in -kind; specify: nature
value
14. Brief description of services performed or to be performed and date(s) of service, including officer(s), employee(s), or member(s)
contacted, for payment indicated in 11:
(Attach Continuation Sheet(s) if necessary)
15. Continuation Sheet(s) attached: Yes F� No
16. Information requested through this form is authorized by Title 31 U.S.C. Section 1352.
This disclosure of lobbying activities is a material representation of fact upon which
reliance was placed by the tier above when this transaction was made or entered into.
This disclosure is required pursuant to 31 U.S.C. Section 1352. This information will
be reported to the Congress semi annually and will be available for public inspection.
Any person who fails to file the required disclosure shall be subject to a civil penalty of
not less than $10,000 and not more than $100,000 for each such failure.
Federal Use Only:
FORM SPI CNS 280F (Rev. 8/05)
Signature:
Print Name:
Title:
Telephone No,: Date:
Authorized for Local Reproduction
Standard Form LLL
OSPI /Child Nutrition Services
Attachment 12 to Bulletin No. 057 -11 CNS
September 30, 2011
DISCLOSURE OF LOBBYING
ACTIVITIES
Complete this form to disclose lobbying activities pursuant to 31
U.S.C. Section 1352 by OMB
ed
Approved d
(See reverse for public burden disclosure.)
1. Type of
Federal Action: 2. Status of Federal Action:
3. Report Type:
F-1 a
b.
contract
grant
F-1
a. bid/offer /application
b. initial award
a. initial filing
F1 b. material change
c.
cooperative agreement
c. post -award
d.
loan
For Material Change Only
e.
f.
loan guarantee
loan insurance
year quarter
date of last report
4. Name and Address of Reporting Entity:
Prime Subawardee
Tier if known:
Congressional District, if known:
6. Federal Department/Agency:
5. If Reporting Entity in No. 4 is Subawardee, Enter Name and
Address of Prime:
Congressional District, if known:
7. Federal Program Name /Description:
CFDA Number, if applicable:
8. Federal Action Number, if known: 9. Award Amount, if known:
10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if
(if individual, last name, first name, middle initial): different from 10.a.)
(last name, first name, middle initial):
(Attach Continuation Sheet(s) SF -LLL,A If necessary)
11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply):
actual ❑planned a retainer
b. one -time fee
c. commission
12. Form of Payment (check all that apply): d. contingent fee
a cash e. deferred
f. other, specify:
b. in -kind; specify: nature
value
14. Brief description of services performed or to be performed and date(s) of service, including officer(s), employee(s), or member(s)
contacted, for payment indicated in 11:
(Attach Continuation Sheet(s) if necessary)
15. Continuation Sheet(s) attached: Yes F� No
16. Information requested through this form is authorized by Title 31 U.S.C. Section 1352.
This disclosure of lobbying activities is a material representation of fact upon which
reliance was placed by the tier above when this transaction was made or entered into.
This disclosure is required pursuant to 31 U.S.C. Section 1352. This information will
be reported to the Congress semi annually and will be available for public inspection.
Any person who fails to file the required disclosure shall be subject to a civil penalty of
not less than $10,000 and not more than $100,000 for each such failure.
Federal Use Only:
FORM SPI CNS 280F (Rev. 8/05)
Signature:
Print Name:
Title:
Telephone No,: Date:
Authorized for Local Reproduction
Standard Form LLL
OSPI /Child Nutrition Services
Attachment 12 to Bulletin No. 057 -11 CNS
September 30, 2011
INSTRUCTIONS FOR COMPLETION OF DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether subawardee or prime federal recipient, at the initiation or receipt of a
covered federal action, or a material change to a previous filing pursuant to Title 31 U.S.C. Section 1352. The filing of a form is required for each
payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employee of any agency, a
member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with a covered federal action.
Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of
Management and Budget for additional information.
1. Identify the type of covered federal action for which lobbying activity is and/or has been secured to influence the
outcome of a covered federal action.
2. Identify the status of the covered federal action.
3. identify the appropriate classification of this report. If this is a follow -up report caused by a material change to the
information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last
previously submitted report by this reporting entity for this covered federal action.
4. Enter the full name, address, city, state and zip code of the reporting entity. Include congressional district, if known.
Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward
recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the first tier. Subawards
include but are not limited to subcontracts, subgrants and contract awards under grants.
5. If the organization filing the report in Item 4 checks "subawardee then enter the full name, addressee, city, state and zip
code of the prime federal recipient. Include congressional district, if known.
6. Enter the name of the federal agency making the award or loan commitment. Include at least one organizational level
below agency name, if known. For example, Department of Transportation, United States Coast Guard.
7. Enter the federal program name or description for the covered federal action (Item 1). If known, enter the full Catalog
of Federal Domestic Assistance (CFDA) number for grant, cooperative agreements, loans, and loan commitments.
.8. Enter the most appropriate federal identifying number available for the federal action identified in Item 1 (e.g., Request
for Proposal (RFP) number; Invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan
award number; the application proposal control number assigned by the federal agency). Include prefixes, e.g., "RFP-
DE -90 -001."
9. For a covered federal action where there has been an award or loan commitment by the federal agency, enter the
federal amount of the award /loan commitment for the prime entity identified in Item 4 or 5.
10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified
in Item 4 to influence the covered federal action.
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a). Enter
last name, first name, and middle initial.
11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (Item 4) to the lobbying
entity (Item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that
apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made.
12. Check the appropriate box(es). Check all boxes that apply. If payment is made through an in -kind contribution, specify
the nature and value of the in -kind payment.
13. Check the appropriate box(es). Check all boxes that apply. If other, specify nature.
14. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to perform,
and the date(s) of any services rendered. Include all preparatory and related activity, not just time spent in actual
contact with federal officials. Identify the federal official(s) or employee(s) contacted or the officer(s), employee(s), or
member(s) of Congress that were contacted.
15. Check whether or not a Continuation Sheet(s) is attached.
16. The certifying official shall sign and date the form, print his/her name, title, and telephone number.
le N
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-
0046), Washington, D.C. 20503.
I/
FORM SPI CNS 28OF (Rev. 8105) OSPI /Child Nutrition Services
Attachment 12 to Bulletin No. 057 -11 CNS
September 30, 2011
OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION AGREEMENT NUMBER
Child Nutrition Services
Old Capitol Building
PO BOX 4720D
OLYMPIA WA 98504 -7200
CHILD AND ADULT CARE FOOD PROGRAM
PROCUREMENT STANDARDS
The procurement standards are a combination of the provisions contained in the U.S. Department of Agriculture, Food and
Nutrition Service regulations and other federal regulations as follows:
U.S. Department of Agriculture, Food and Nutrition Service regulations.
7 CFR Part 226 Child and Adult Care Food Program.
7 CFR 3019 Uniform Administrative Requirement for Non Profit Organizations.
7 CFR 3016 Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local
Governments.
OMB Circular A -122 Allowability of Costs for Non Profit Organizations.
FNS Instruction 796 -2 Revision 3 Allowable Cost Rules.
More restrictive standards may apply per state law or organization procurement policies and procedures.
These standards are a mandatory requirement and apply to all items purchased by institutions for food, supplies,
equipment, and other goods and services. This document applies to all officers, employees, and agents acting on behalf of
the institution. If a conflict arises between these procedures and those established by a government body, procedures that
bear legal superiority will take precedence.
Procurement Procedures
All institution procurements must comply with USDA Memorandum CACFP 09 -2008 and with 7 CFR 226.22 (d)
through (h) sections. All institutions who estimate a purchase greater than or equal to $100,000 must formally
procure this purchase. Institution types will follow procedures as set forth:
Proprietary (for profit) institutions -7 CFR 226.22.
Private nonprofit institutions -7 CFR 3019.41 through 7 CFR 3019.48.
Public agency institutions -7 CFR 3016.36.
In all of the above cases, if there are regulations or institution policies and procedures establishing a small
purchase threshold less than $100,000, then a formal procurement process is required for goods and services.
For public agency institutions a person or entity that develops or drafts specifications, requirements, statements of
work, invitations for bid, requests for proposals, contract terms and conditions, or documents specifically for use
by an institution in conducting procurement shall be excluded from competing for such procurements per (7 CFR
Part 3016.36[b]).
Pursuant to Sec. 3016.36(b)(12), public agency institutions must have protest procedures in place to handle and
resolve disputes relating to their procurements and must in all instances disclose information regarding a protest
to their state agency.
An institution may not sign a contract with a party that has been debarred or suspended (i.e., is ineligible) per
7 CFR 3017. Non federal entities are prohibited from contracting with or making subawards under covered
transactions to parties that are suspended or debarred or whose principals are suspended or debarred. Covered
transactions included procurement contracts for goods or services equal to or in excess of $25,000. When a non-
federal entity enters into a covered transaction with an entity at a lower tier, the non federal entity must verify that
the entity is not suspended or debarred or otherwise excluded. This verification may be accomplished by checking
the Excluded Parties List System (EPLS) maintained by the General Services Administration (GSA) at
www.eDIs. ov collecting a certification from the entity, or adding a clause or condition to the covered transaction
with that entity. Institutions should keep documentation of this verification.
OSPI /Child Nutrition Services
FORM SPI CNS 1136PS (Rev. 8/10) 1 Attachment 13 to Bulletin 057 -11 CNS
September 30, 2011
There are two types of procurement procedures depending on the total costs:
A. For all institutions, purchases greater than $100,000 are considered a large purchase and must include
one or more of the following methods of procurements: Invitation for Bid (IFB) or Request for Proposal
(RFP) or sole source. Descriptions of each procedure are provided below (see also General Provisions):
Invitation for Bid (IFB)
This procedure will be used when an adequate and realistic product or service description is
available. It will not be used unless there are two more responsible suppliers willing and able to
compete effectively for the business and there is every intention of selecting the successful bidder
principally on the basis of price. No awards will be made under this procedure unless at least two
bids have been received.
Formally advertised, sealed bids are publicly solicited and a firm fixed price contract is awarded to
the responsible bidder whose bid conforms to the terms and conditions of the IFB.
Institutions must meet the following requirements when formally advertising an invitation
for bid:
(1) Institutions must advertise and publicly announce the proposed contract at least
14 calendar days before the opening of bids. The announcement must include
the time and place of the bid opening and information about obtaining a copy of
the complete specification for the institution's proposed purchase.
(2) At least two weeks before the bid opening date, bids will be solicited from an
adequate number of known suppliers. These shall include suppliers listed in the
local telephone book, purchasing directors, or names of suppliers on solicitation
lists to include minority, small, and women's business enterprises. In addition, the
invitation to bid will be posted in a public place or otherwise advertised.
(3) A complete, adequate, and realistic specification or purchase description will be
part of the IFB. Menus will be part of any solicitation for a food service
management company.
(a) Only nonfood items necessary for the food service (such as straws,
napkins, or packaging) can be included in the IFB.
(b) The IFB must be so clear and accurate that all prospective bidders will
have an equal chance of award of the contract.
(c) The IFB may not provide for loans or other monetary benefits, terms, or
conditions to be made to institutions by commercial vendors.
(4) Factors such as price, quality, ability to perform, character, deadlines, prior
experience, etc., as well as discounts, transportation costs, and life cycle costs
will be considered in determining which bid is low only if so specified in the IFB.
(5) Any or all bids may be rejected when there are sound documented business
reasons in the best interest of the program.
(6) A written notice of award shall be made to that responsible bidder, whose bid,
conforming to the IFB, is lowest.
(7) All bids shall be opened publicly at the time and place stated in the IFB.
(8) If the institution is not accepting the lowest bid, a justification for awarding the
contract to a higher bidder must be provided.
OSPI /Child Nutrition Services
FORM SPI CNS 1136PS (Rev. 8/10) 2 Attachment 13 to Bulletin 057 -11 CNS
September 30, 2011
2. Request for Proposal (RFP)
This procedure, also called competitive negotiation, will be used when it is impossible to prepare a
realistic specification or the award cannot be made principally on the basis of price. In competitive
negotiation, a request for proposal will be publicized and a number of suitable sources will be
requested to submit proposals. Negotiations will be conducted with two or more of the firms
submitting offers. This method may be used only if conditions are not appropriate for the use of
formal advertising (IFB's).
a. Procedures are as follows:
(1) Requests for proposal shall outline the procedures and evaluation factors that will
be used to identify and select responsible offerors for negotiation as well as the
criteria that will be used to make the final selection for contract award.
(2) Award will be made to the responsible offeror whose proposal will be most
advantageous to the sponsor with price and other factors considered.
Unsuccessful offerors will be notified immediately when a contractor is selected.
3. Sole Source
This is noncompetitive negotiation in procurements through solicitation of a proposal from only
one source. Noncompetitive negotiation may be used only when award of the contract is not
feasible under the IFB or RFP procedures.
a. Noncompetitive negotiations are limited to the following:
(1) The item is available only from a single source.
(2) An emergency requirement exists.
(3) Competition is determined to be inadequate.
(4) OSPI authorizes noncompetitive negotiation.
B. Institutions with aggregate purchases less than the $100,000 small purchase threshold may use an
informal process. An aggregate amount is the sum total of materials or services which can logically be
purchased from one vendor during one fiscal year. Institutions must have documented evidence of open
and free competition at the best price. Price or rate quotations must be obtained from an adequate
number of qualified sources. Small purchases shall be documented. At a minimum, documentation shall
include the date; vendors contacted, item description, prices quoted, and any delivery data. Whenever
only one quotation is received, documentation must include written justification for the purchase. The
following procedure must be observed:
Small Purchase Procedures
1. Price comparisons may be used.
2. Institution policy and procedures may require an IFB or RFP under the $100,000 small purchase
threshold which is permissible and encouraged.
General Provisions —for IFB, RFP, Sole Source
Award Approval
OSPI must approve contracts that meet the following criteria. The procurement is proposed as a sole source
procurement and will be awarded without competition.
Geographic Preference
Section 90) of the Richard B. Russell National School Lunch Act was amended by the 2008 Farm Bill to
encourage institutions to use a geographic preference when purchasing unprocessed agricultural products, both
locally grown and locally raised. The geographic preference does not guarantee a certain percentage or level of
OSPI /Child Nutrition Services
FORM SPI CNS 1136PS (Rev. 8/10) 3 Attachment 13 to Bulletin 057 -11 CNS
September 30, 2011
business, but gives bidders located in a certain geographic area a specific and defined advantage in the
procurement process.
III. Code of Conduct
This code of conduct shall govern the performance of all officers, employees, and agents engaged in the award
and administration of contracts supported by federal funds.
A. It shall be a breach of ethical standards for any employee, officer, or agent to participate directly or
indirectly in the selection, award, or administration of a contract supported by federal funds when the
employee knows that:
The employee, officer, agent, or any member of his immediate family has a financial or other
interest pertaining to the procurement.
2. A business or organization in which the officer, employee, agent, or any member of his immediate
family has a financial or other interest pertaining to the procurement.
Any other person, business, or organization which the employee, officer, agent, or any member of
his immediate family is negotiating with or has an arrangement concerning prospective
employment is involved in the procurement.
B. All officers, employees, or agents shall neither solicit nor accept gratuities, favors, or anything of monetary
value from contractors, potential contractors, or parties to sub agreements.
C. In the event of violations of this code, officers, employees, or agents are subject to the following penalties
or disciplinary action:
1. Reprimand.
2. Suspension.
3. Termination of employment.
IV. Responsibilities
These standards shall not relieve the sponsor(s) of any contractual responsibilities under their contracts. The
institution is responsible, in accordance with good administrative practice and sound business judgment, for the
settlement of all contractual and administrative issues arising out of procurements entered into in support of the
program. These include, but are not limited to:
A. Contractual responsibilities /administrative issues:
1. Source evaluation.
2. Protests of award.
3. Disputes.
4. Claims.
B. Other responsibilities are as follows:
All proposed procurement actions shall be reviewed to avoid purchases of unnecessary or
duplicate items.
2. Procurement procedures shall not restrict or eliminate competition. Examples of restrictive
practices include, but are not limited to:
a. Placing unreasonable requirements on potential bidders' firms in order for them to qualify
for the contract award.
OSPI /Child Nutrition Services
FORM SPI CNS 1136PS (Rev. 8110) 4 Attachment 13 to Bulletin 057 -11 CNS
September 30, 2011
b. Noncompetitive practices between bidders.
C. Organizational conflicts of interest.
d. Unnecessary experience and bonding requirements.
3. Technical requirements for the material, product, or service to be procured shall be clearly and
accurately described. The description will not contain features that unduly restrict competition.
4. Contracts shall be awarded only to responsible contractors that possess the potential to perform
successfully under the terms and conditions of the proposed procurement. Consideration will be
given to contractor integrity, compliance with public policy, record of past performance, and
financial and technical resources.
5. The cost plus a percentage of cost method of contracting is prohibited.
V. Procurement Records
The following records shall be retained for each procurement:
A. Records sufficient to detail the significant history of a procurement shall be maintained for three years
from the end of the federal fiscal year to which these records pertain.
B. These records shall include, but are not necessarily limited to:
1. Information pertinent to the rationale for the method of procurement.
1 Selection of contract type.
3. Contractor selection or rejection.
4. The basis for the cost or price.
C. Recommended documentation:
1. The advertisement or public notice used to publicize the procurement or an affidavit of publication.
2. The solicitation letter forwarded to prospective vendors along with any replies received from
prospective vendors.
3. The IFB or RFP.
4. The proposed contract (completed by the vendor in response to IFB or RFP).
5. Any other information necessary to explain or justify the particular procurement method(s) utilized,
cost benefits determination, etc.
CERTIFICATION STATEMENT
I have read and understand my responsibilities as listed on these procurement standards. Our organization will adopt
these procurement standards for all purchases using USDA funds. Our organization understands that more restrictive
procurements may be required by state law or adopted by o r organization.
-L1o" z5 ao /a,
Signat esignat6d Official or Owner(s) Date
l/ U
v
RETURN ADDRESS: Child Nutrition Services
Office of Superintendent of Public Instruction
PO Box 47200
Olympia, WA 98504 -7200
OSPI /Child Nutrition Services
FORM SPI CNS 1136PS (Rev. 8/10) 5 Attachment 13 to Bulletin 057 -11 CNS
September 30, 2011