Valid Child and Adult Care Food Program (CACFP) At-Risk Unaffiliated Site Questionnaire/Attestation

Please read this guidance and form instructions carefully.

Policy

Child and Adult Care Food Program (CACFP) Contracting Entities (CEs) must maintain operational oversight and have full control over the management and administration of the food program at all unaffiliated sites under their sponsorship for the duration of their program participation (7 CFR 226.16(d)). CACFP CEs sponsoring At-Risk sites may contract with a unitized meal vendor (vended meal provider) or Food Service Management Company (FSMC) to manage food service operations at a site, but the vendor/FSMC must:

Be properly procured by the CE; and
The CE must have a signed and TDA-approved Contract for Purchased Meals with the vendor/FSMC.

Unitized meal vendors and FSMCs must not represent themselves as an unaffiliated site. A signed Permanent Agreement (site agreement) between a CE and a meal vendor/FSMC in lieu of a properly procured Contract for Purchased Meals is not valid, and sites established under such agreements cannot claim meals for reimbursement.

To ensure that all unaffiliated sites are valid and under the CE’s operational control, all CEs sponsoring unaffiliated At-Risk sites must attest via this form that all sites meet one of the following requirements:

Site agreements are signed by staff affiliated with the location where the meals are being served (for example, if the unaffiliated site is a school, then school staff are responsible for direct oversight of the CACFP At-Risk program); or
If the site agreement is with an organization not affiliated with the location of service (for example, at an apartment complex), the organization signing the permanent site agreement:
Is providing a comprehensive Afterschool Program, including congregate enrichment activities and food service. NOTE: CACFP funds cannot be used to procure supplies, staff, or materials associated with the enrichment.
Must have a signed Memorandum of Understanding between the site level organization managing the At-Risk program and the location of service approving the operation of an At-Risk program onsite. A copy of this agreement must be maintained by the CE and provided at the time of site application.

Form Instructions

For each unaffiliated At-Risk site under its sponsorship, the CE must be able to address the following questions in this form to meet compliance. Once this attestation form is submitted, TDA may reach out to you for more information

NOTE: CEs may submit this form multiple times. For example, you may submit this form for the sites you know meet compliance while investigating sites for which you are uncertain. Any new unaffiliated sites added after submittal of this form will require submittal of this form for the new site before that site application can be approved.

1. Select CE Name from the drop-down menu.

2. Do you have unaffiliated sites under your sponsorship that are managed by staff affiliated with the location of service?

The site agreement will be signed by staff of the location where meals are served.

Yes

No

3. Do you have unaffiliated sites under your sponsorship that are managed by a sub-sponsor?

A sub-sponsor is an organization that signs the site agreement but is not legally affiliated with the site where the At-Risk Program and CACFP meal service is taking place.

Yes

No

4. For every unaffiliated site listed in both Questions 2 and 3 above, you must attest to the following statements. If during an Administrative Review, TDA discovers any non-compliance with the below attestation statements, meal disallowances and closure of the site may result:

I attest that for each site listed in this form, the organization signing the site agreement is operating a nonprofit food service.

I attest that for each site listed in this form, the organization signing the site agreement is operating a nonprofit food service.

I attest that for each site listed in this form, I am providing written documentation that details the reimbursement the site is receiving each claimed month.

I attest that for each site listed in this form, I am providing written documentation that details the reimbursement the site is receiving each claimed month.

I attest that for each site listed in this form, the organization signing the site agreement is not also using CACFP funds they receive for administrative purposes.

I attest that for each site listed in this form, the organization signing the site agreement is not also using CACFP funds they receive for administrative purposes.

I accept full responsibility for the operation of the program at the sites listed in this form.

I accept full responsibility for the operation of the program at the sites listed in this form.

I accept final administrative and financial responsibility for Program operations at the sites listed in this form.

I accept final administrative and financial responsibility for Program operations at the sites listed in this form.

I am obtaining and maintaining the government issued identification for the principals of each site listed in this form.

I am obtaining and maintaining the government issued identification for the principals of each site listed in this form.

I am obtaining and maintaining the business filings and formation documents (e.g., Articles of Incorporation, Certificate of Formation), Assumed Name Certificate, and IRS 501 (c)(3) tax-exemption (if applicable) for each sponsored site.

I am obtaining and maintaining the business filings and formation documents (e.g., Articles of Incorporation, Certificate of Formation), Assumed Name Certificate, and IRS 501 (c)(3) tax-exemption (if applicable) for each sponsored site.

I am providing the following oversight functions at each site listed in this form:

Conducting direct monitoring.

Reviewing all the menus of the sites as well as ensuring the meal production records at each site are being completed.

Conducting pre-approval visits.

Adding/submitting changes for and terminating sites.

Ensuring sites maintain current license/certification and enrollment documents.

Ensuring all health and safety documentation is maintained and provided to TDA.

Ensuring the site is providing afterschool educational or enrichment activities, either directly or via a procured vendor, to participants on each day of meal service.

Providing technical assistance.

Ensuring organizations submitting sites for participation are not disqualified from participation in any Child Nutrition Program, as well as ensuring site staff in principal positions or performing CACFP functions are not disqualified.

I attest that I am providing the initial and annual training to the staff of the organizations managing the sites listed in this form.

I attest that I am providing the initial and annual training to the staff of the organizations managing the sites listed in this form.

I understand that for any existing site for which I cannot attest to any of the above, that site must be closed with an effective closure date of no later than September 30, 2024. Any site not closed and/or not submitted via this attestation form by July 1, 2024, will be closed by TDA on behalf of the CE.

I understand that for any existing site for which I cannot attest to any of the above, that site must be closed with an effective closure date of no later than September 30, 2024. Any site not closed and/or not submitted via this attestation form by July 1, 2024, will be closed by TDA on behalf of the CE.

Check that each of the following statements is true:

I am an Authorized Representative (AR) of the Contracting Entity (CE) listed on the “FND-101, CERTIFICATE of AUTHORITY for EXTERNAL USERS” or “FND-135, USER ACCESS MANAGER FORM” that has been approved by TDA prior to this submission of this waiver notification.

I am an Authorized Representative (AR) of the Contracting Entity (CE) listed on the “FND-101, CERTIFICATE of AUTHORITY for EXTERNAL USERS” or “FND-135, USER ACCESS MANAGER FORM” that has been approved by TDA prior to this submission of this waiver notification.

I certify that the CE has retained documentation related to the information submitted in this attestation form.

I certify that the CE has retained documentation related to the information submitted in this attestation form.

I understand that it is the CE’s RESPONSIBILITY TO MAINTAIN COMPLETE OPERATIONAL CONTROLL OVER ALL SITES LISTED IN THIS FORM IN ACCORDANCE WITH APPLICABLE REGULATIONS and that NON-COMPLIANCE MAY RESULT IN ADVERSE FISCAL ACTION.

I understand that it is the CE’s RESPONSIBILITY TO MAINTAIN COMPLETE OPERATIONAL CONTROLL OVER ALL SITES LISTED IN THIS FORM IN ACCORDANCE WITH APPLICABLE REGULATIONS and that NON-COMPLIANCE MAY RESULT IN ADVERSE FISCAL ACTION.

I understand that any sites not listed in this attestation form will be closed by TDA with an effective date of September 30, 2024 prior to Program Year 2025.

I understand that any sites not listed in this attestation form will be closed by TDA with an effective date of September 30, 2024 prior to Program Year 2025.

I am employed by the CE named on this waiver. I am not an employee of a Food Service Management Company (FSMC).

I am employed by the CE named on this waiver. I am not an employee of a Food Service Management Company (FSMC).

Name of Authorized Representative:

First Name

Last Name

Each party acknowledges and agrees that information in this form is attested to by the name entered in the field above and shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature.

After the form is submitted, you will receive a confirmation email message with a copy of your submitted response. Please save the email for your records.

Contact Name

First Name

Last Name

Contact Email

example@example.com

Contact Phone

Include Area Code

Phone

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