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HomeMy WebLinkAboutGrant DocumentsFlorida Department of Health: Child Care Food Program Page 1 of 2 Save Appjaypstiltitigghr Sponsor of Affiliated Child Care Centers Print Preview a S- 576 Region: S RPS: 5 Fiscal Year: 2014 • Legal Name: CITY OF MIAMI DAY CARE PROGRAMS D/B/A: CITY OF MIAMI DAY CARE Other AN#(s): 1) linter the eslilnnled annual Poore Service (Operational) casts to be charged to the Child Care Fond Program. Food Service (Operational) Costs CCFP Funds Food Purchases $67,217 Food Service Labor and Benefits Non -Contracted Purchased Services Non -Food Supplies Food Service Equipment Transportation Other (Includes Special Cost Items) 'rotal Costs (calculated) $67,217 Description of Costs Name(s) Funding from of Other Other Sources Funding Source(s) $0 2) linlor Ihr stir oicd annual Administrative Casts In he charged to the Child Care Pond Program. Administrat• ive CCFP Funds Costs Administrative Salaries and $11,244 Benefits Non - Contracted Purchased Services Training Travel Rent and Utilities Office Supplies Other (Includes Special Cost Items) Total Administrative $11,244 Costs (calculated) Budget Grand Total $-7.11'4131 Description of Costs Funding from Other Sources Total Funding $67,217 $0 $0 $0 $o $0 $0 $67,217 Names) of Other Funding Source(s) $494 $494 $494 Upload Supporting Document for Applicable Budget Costs: Total Funding $11,738 $0 $0 $0 $0 $0 $0 $11,738 https://adminappsdoh35.doh.state.fl.us/CCNS/S/SBudgetWorksheet.aspx 8/20/2014 1.2•••••,....m.11.1,s1111• Florida DepartMent ofi-lealth Child Care Food Program child Oare rood PrOgrOM App.110.tion POP' 1. of 4 A/21/2014 1047M . .S.,•62,s...... ,Region; ..§... :RFS: ',Pisoal Year: 2014 ' .5eId Cate; --.....L..„:. TonleatIon bete: . . Acr..cl'I EN1-01' Racialtetr:• itbR Reagan: . Meal OlsalloWance;•' , Legal,Nainel CITY C/F MIAMI DAY CAR!. PROORAM8.• FEINt 6960007,6118 , . . ...... 0/P/A: CITY OF MIALVIIIZAY 0 F&Z. , DUNS t 072g20191, ..„. PrPair0 PO% .461,c)/198 brig, Pay..6tart bate: 10/1/1996 Payment 'tftftbeta: :1911/2013 Last Updated; :I /27/2013 ,,1 • 1). IC? rOallizettpn,A4, dreaaen ON: Name (D/S/A)! gay o rit(tAlyiipAY CARE • Street Atic4ss: 495 N. E. 51&T ST Err • • 0156' MIAMI 8fele;* FL Zip' '13187-22'2.1 C•clutq' DIAba Cheek fiex if Maillitg Address is same ae Street Addresa(lf not fill In Marling Address below) Malkin Adereae: P. •(;), Ac:p( 330706 city: MIAMI ,Biate: yt., ..ZIP: 'M. 2i53079c1 COuniy: DAIV — CcimPiate,RernIt Address if youvant the pirOot POPOstt notiee or ebeel5 sent sonieWilere ether than he aboVe Mailing Address Remit Address: City: • • State: •21p: County; 24 Board Choir/flan /0E0 1 President 1 Majority Owner/6(Mo°' Superintendent inforrhation i J. .<-1Alfonso I. Salutation; MR, rirstrName: . JOHNNY < 'Dan el I Last warne: .16,kfiTit+67 Title; QM MANAGER C.0.5, (MM/DD/WW) am/061 <15/27/68 Email Address: Melling Address: (Multt I* difreroni koin address proyldsd above In itri) BOX 330708 .13,0 ,City: Mat State! FL 'ZIP: :33203 P,hene;. 305 1 250 - 5400 Fit . NIX: ( 306 ) 260 -6416 2) PO.PP.Program Manager InfOralatJain (primary •paraoa raaponalblo forfood program tidministratioti), Salutation: 11/IRS: First Name: •01-IRISTI. 'Iatet Name: 120.5. (MWOD/YYYY): 8/30/1955. E-rnall Address: olongainiamigov.coM , ..., Pilane: 4 a05 ) 7.9 - 3507 Ext. Foe 4) Typo of OrgantzatIort: GOVERNMENT ANY Florida Department of Health Child Care Food Program Paget of 4 8/21/2014 10:47AM C(ild_Care Food Program Application AN: 576 FY: 2014 DIB/A: CITY OF MiAMI DAY CARE 5) Shareholder Information First Name: First Name: First Name: First Name: Shareholders are only required for'For-Profit' organizations Last Name: DOB: Last Name: DOB: Last Name: DOB: Last Name: DOB: % Ownership: % Ownership: % Ownership: % Ownership: 6) Enter your organization's fiscal year end date: (For example, if September 30th enter 0a/30) 10/31 (Month/Day) 7) Is your organization a non-profit entity or a non-federal governmental entity that expended $500,000 or mare In federal funds during its most recent fiscal year? If yes, your organization must meet the requirements of the Single Audit Act (OMB Circular No. A-133). ourgrgemsatier a c{�s3rchlxyrtegmguelte pfe nsgpetitattr3eetstfr tEtS wrements to be exempt from fetferaf rncamame tax imdec section { 31 of emal Fzevenue'Cci 9) Does your organization currently have other authorization number(s) with the Bureau of Child Care Food P.rograms? if yes, indicate other authorization number(s): X Yes No Yes X No Yes X No 10) Does your organization have a contract to participate in the Child Care Food Program in Yes X No any state(s) other than Florida? If yes, Indicate which state(s): 11) Prospective contractor will submit a news release to .the media that notifies the public, including minority and grassroots organizations, about the CCFP. 12) Organization accepts all participants regardless of race, color, age, sex, disability, or national origin. 13) For this fiscal year, your organization would prefer to receive? 14) Estimated percentages of the ethnic makeup of the AREA to be served: Hispanic or Latino Not Hispanic or Latino Total 10% 90% 100% x Yes No X Yes �N X Cash -In -Lieu USDA Donated Foods Florida Department of Health Child Care Food Program Page 3 of 4 8/21/2014 10:47AM Child Care Food:' Program Application AN: 576 FY: 2014 D/B/A: CITY OF MIAMI DAY CARE 15) Estimated percentages of the racial makeup of the AREA to be served: American Indian or Alaskan Native White Black/African American Asian Native Hawaiian or other Pacific Islander Total 0% 3% 97% 0% 0% 100% 16) Month(s) contractor will NOT operate in this fiscal year: (check all that apply) October November December January April May June February March July _ August September 17) Will you be using Review Averaging for this fiscal year? (Refer to Section 4.1 of your CCFP Procedure Manual for a description of the Review Averaging Option.) 18) Do you sponsor or plan to sponsor any centers that are separate legal entities from the sponsoring organization? (For -profit organizations are EA eligible to sponsor centers that are separate legal entities,) Complete the next question only if you answered "yes" to quuestion # 18 above. 19) List the counties where you intend to recruit and sponsor unaffiliated child care centers on the CCFP: Yes x No Yes x No (Note: Prior DOH approval is required for each county where you plan to sponsor unaffiliated centers. Refer to Sections 1.1 and 1.13 of the Procedure Manual for Sponsors of Unaffiliated Centers for more information.) Total number of children enrolled for sponsor by ethnic category: Hispanic or Latino Not Hispanic or Latino Total 16 87 103 Total number of children enrolled for sponsor by racial category: American Indian or Alaskan Native White Black/African Asian Native Hawaiian or Total American other Pacific Islander 0 26 77 0 0 103 Florida Department of Health Child Care Food Program Page 4 of 4 8/21 /2014 10:47AM hlld Care. Food:: Program Application Types of Centers Sponsored Private Non -Profit Outside School Hours Military Head Start 0 AN: 576 FY: 2014 D/B/A: CITY OF MIAMI DAY CARE For -Profit For -Profit Outside School Hours Public Total Centers 1 certify that all information on the Application and Budget is true and correct. 2 2 Signature of Authorized Representative Title Printed Narne Date Florida Department of Health Child Care Food Program MANAGEMENT PLAN (For Sponsors of Affiliated Child Care Centers, Afterschool Meals Programs, and Homeless Children Nutrition Programs) Authorization Number: Sponsoring Organization Name: Instructions: Complete the following Management Plan information. Follow the directions provided for each table to be completed. Attach additional sheets and other documentation as requested. 1. ADMINISTRATIVE STAFFING for CCFP - Complete this table listing all personnel who will perform CCFP administrative duties. Administrative duties include program management, monitoring, compiling meal counts, classifying meal applications, maintaining enrollment rosters, training, accounting, reviewing & filing the claim, etc, Administrative duties do not include preparing or serving meals, Attach additional sheets as needed using the following table format. (A) Employee Name {B} Position Title (C) List of Specific CCFP Administrative Duties Performed (D) Hours per Month Spent on CCFP (E) X ft of CCFP Operating Months per Year (F) = Annual Hours Spent on CCFP (G) / Total Annual Hours Worked (H) Time Spent on CCFP NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN Revised 4/2014 Paget of 4 s-006-10 Authorization Number: Sponsoring Organization Name: 2. ADMINISTRATIVE SALARIES & BENEFITS - Complete this table listing all personnel listed above in table 1. The total administrative costs charged to the CCFP cannot exceed 15% of projected or actual meal reimbursements. The amounts listed in column G cannot be more .than the amounts listed in column F, and may need to be less in order to stay within the 15% administrative cost limit. Attach additional sheets as needed using the following table format. (A) Employee Name (8) Annual SalarybyEmployer (C) + Annual insurance & Other Benefit Costs Paid p (D) =Total Annual Salary & Benefits (E) o X l Time Spent an CCFP (from column H in Table 1) (F) =Total Annual Salary Benefits Cost for Time Spent on CCFP (G) Amount to be Charged to the CCFP (H) Amount to be Charged to Other Funds (difference of column F minus Column G amount) Health Dental Life Retirement Other $ 0.00 NaN $ 0.00 $ 0.00 $ 0.00 NaN $ 0.00 $ 0.00 $ 0.00 NaN $ 0.00 $ 0.00 $ 0.00 NaN $ 0.00 $ 0.00 $ 0.00 NaN $ 0.00 $ 0.00 $ 0.00 NaN $ 0.00 $ 0.00 $ 0.00 NaN $ 0.00 $ 0.00 $ 0.00 NaN $ 0.00 $ 0.00 $ 0.00 NaN $ 0.00 $ 0.00 $ 0.00 NaN $ 0.00 $ 0.00 $ 0.00 NaN $ 0.00 $ 0.00 $ 0.00 NaN $ 0.00 $ 0.00 $ 0.00 NaN $ 0.00 $ 0.00 $ 0.00 NaN $ 0.00 $ 0.00 $ 0.00 NaN $ 0.00 $ 0.00 $ 0.00 NaN $ 0.00 $ 0.00 $ 0.00 NaN $ 0.00 $ 0.00 Note: Transfer these totals to the applicable columns on the Administrative Salaries & Benefits row of the Budget > if Qfhpr tmeiv.r rnli,mn r' ;f;lior4 ...t d TOTAL CCFP Funds Other Funds $ 0.00 $ 0.00 $ 0.00 Revised 4/2014 escnbe below the speclfilc benefit{s) being provided to the employee(s): Page 2of4 S-006-10 Authorization Number: Sponsoring Organization Name: 3. The sponsor conducts MONITORING REVIEWS at least as often as required by 7 CFR, Part 226.16(d)(4). Yes _ No _a. A yes answer indicates that the sponsoring organization, at a minimum, conducts unannounced CCFP monitoring reviews as follows: • Each new site is reviewed within the first four weeks of CCFP operations. + Each existing site is reviewed three times yearly with not more than a six-month lapse between reviews. If using review averaging, contractor meets review averaging requirements. • Follow-up reviews are conducted within 30 days of issuing a disallowance and/or identifying areas of noncompliance. 4. How many sites do you currently sponsor? 5. MONITORING STAFF - Complete this section only if your organization sponsors 25 or more sites or if you anticipate sponsoring 25 or more sites during this fiscal year. In the table below, list all employees who perform monitoring activities and describe the specific activities each employee performs. Monitoring activities include, but are not limited to, conducting on -site reviews, planning the review schedule, travel for reviews, supervisory oversight of monitors, writing review reports, follow-up reviews, pre -approval visits, household contacts, technical assistance, and desk reviews of claim documentation. For each employee listed, indicate the total monthly hours spent on the CCFP (refer back to table 1, column D), and the percentage of those hours spent on monitoring; then multiply the two figures to obtain the number of hours per month spent on monitoring. Add the monitoring hours of all employees listed to obtain the total for the sponsoring organization. Attach additional sheets as needed using the following table format. Please Note: Monitoring ratios for sponsors must equal at least one FTE (2080 hours/year or 173.33 hours/month) for 25 to 150 sites. See below for more detail. Employee Name Description of Monitoring Activities Total Hours per Month Spent on CCFP (from table 1, column D) % of Monthly CCFP Hours Spent Monitoring # of Hours per Month Spent on Monitoring* (Total monthly CCFP hours x % of hours monitoring) 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00% Q.00 TOTAL = 0 * Sponsors with twenty-five (25) or more sites are required to employ at least one full time equivalent (FTE) monitor per 25-150 sites. However, to ensure adequate monitoring, there should be approximately one FTE monitor for not more than 85 sites. An FTE equals one staff year (2080 hours) or a staff month (173.33 hours) and could be one full time staff person who monitors full time; two half time staff who spend all of their time monitoring; two full time staff who spend half of their time monitoring; three full time staff, one of whom monitors 40% of the time, with the other two each spending 0% of their time monitoring, etc. Revised 4/2014 Page 3of4 S-006-10 Authorization Number: Sponsoring Organization Name: 6. Complete the table below outlining your proposed TRAINING SCHEDULE for administrative staff (such as, monitors, trainers, clerks, secretaries, bookkeepers), and food service personnel (such as, cooks and meal assistants). Attach additional sheets as needed using the following table format. A sign -in sheet and an agenda must be maintained for each session. Training on all required topics must be conducted at least once per year. Date of Proposed Training Instructor Name(s) Required Training Topics • Menu Planning & Meal Pattern Requirements • Meal Count Procedures • Claim Review & Submission Procedures • Reimbursement System • Civil Rights Requirements Recommended Training Topics • Food Safety & Sanitation • Nutrition Education 7. The sponsor reviews all CCFP records for accuracy and compliance. Yes (") 8. List the Florida address(s) where CCFP records will be maintained: No 0 certify that all information on the Management Plan is true and correct. Signature of Sponsor Representative Printed Name Revised 412014 Date Program Manager Title Page 4 of 4 s-006-10 Florida Department of Health Child Care. Food Program BOARD OF DIRECTORS CERTIFICATION for private, not -for -profit organizations Auth. #: I certify that the listed individuals constitute the full governing board of the institution that is contracting with the Florida Department of Health, and that this board is responsible for Child Care Food Program oversight. If attaching a separate list of board members, it must include addresses and phone numbers, and you must still complete the last two columns below for each board member and sign the back of this form. Please see back of form for board criteria. NOTE: Date of Birth is required only for the chairman/president of the board. Title of PositionInstitution? Held on Board First and Last Name of Board Member and Date of Birth {MM-DD-YY) of Board Chairman/President Mailing Address Phone Number Financial Interest in Yes/No (See reverse side for more information.) Family Relationship to Institution's Personnel or Other Board Members Yes/No Board President Name: DOB: Y N 0 0 �.YN Y N 0 0 0 0 Y N 0 0 Y N 0 0 Y N 0 0 Y N 0 0 Y N 00 Y N 0 0 Y N 0 0 Y N } 0 `-' Y N 0 o Y N 0 0 Y N 0 0 Y N 0 0 Y N 0 0 Revised 8/2013 1 of 2 1-029-11 BOARD OF DIRECTORS CERTIFICATION 1. I certify that, if an incorporated institution, this board is in compliance with all applicable state statutes and rules regarding governing boards of corporations. 2. I certify that, as a private, not -for -profit institution holding federal tax-exempt status, the board meets the following criteria: ■ Board members do not vote on decisions regarding their own compensation or that of a related party. ■ Minutes of board meetings are recorded and made available for review to the Department of Health, Bureau of Child Care Food Programs upon request. The board provides independent oversight and has authority to hire and fire the institution's Executive Director/Chief Executive Officer/ President. • Less than 50% of the board has a direct and/or indirect financial interest in the activities of the institution. Financial interest includes but is not limited to: ownership or investment in the institution, employee of the institution, parent of a child participating in the CCFP through the institution, individual receiving any type of compensation or benefits from the institution. ■ Less than 50% of the board is related by blood or marriage to the institution's personnel or to each other if the institution is/will be participating in the Child Care Food Program as an independent child care center/site or sponsor of affiliated child care centers/sites; howeverif participating as a sponsor of unaffiliated child care centers/sites/day care homes, no board member is related by blood or marriage to the institution's personnel or to each other. 3. I understand that the submission of false information to the Department of Health is grounds for termination from, or denial of participation in, the Child Care Food Program. Institution Name Date Printed Name of Board Chairman, Executive Director, President, or Signature of Board Chairman, Executive Director, President, or Delegated Authority Delegated Authority DOH Use Only: Institution Type (circle): A D H 1 S U Financial Interest: Family Relationship: 2 of 2 Organization Name: City of Miami Day Care Programs Authorization #: 0576 Delegation of Signing Authority for the Child Care Food Program By means of this letter, 1, Daniel J. Alfonso (the Delegating Official, which is the Board Chairman, Executive Director, President or Majority Owner), delegate the authority herein described, to Christine T. Long (my representative), on the following terms and conditions: 1. My representative may sign, on my behalf, any documents pertaining to the Child Care Food Program (CCFP). 2. The designated effective time period of this delegation is as follows: a. For a prospective contractor, this delegation will be in effect from the date that the CCFP application checklist or contract is signed, whichever date occurs earlier, through September 30, 2015 or until revoked in writing by the delegating official, whichever date occurs earlier. b. For a renewing contractor, this delegation will be in effect from the date that the CCFP Annual Information Update and Certification or contract amendment (when applicable) is signed, whichever date occurs earlier, through September 30, 2015 or until revoked in writing by the delegating official, whichever date occurs earlier. 3. The authority delegated is not subject to sub -delegation without my prior and written consent. 4. I understand that this delegation does not relieve me of responsibility to manage and supervise operation of the Child Care Food Program, that I may be liable for repayment of funds received and that I may be subject to disqualification from future participation in the Child Care Food Program should the terms of the contract with DOH for participation in the Child Care Food Program not be fulfilled. Acknowledged and agreed: Revised 4/2014 Signature (Delegating Official) Daniel ,L Alfonso Name Title (Board Chairman, Executive Director, President or Majority Owner) Date Signature (Repr entative Christine T. Long Name Day Care Administrator Title Date I-132-11 Projected Earnings Worksheet -',FY 2014 15 Auth # and/or Organization Name: Requiresltiaer:I nput; 0A•ut4maticalfy Calapiaitas , Please Answer these Questions Average Attend Days Operating nce per bay Number of children eligible for free meals Number of children eligible for reduced meals Number of children eligible for non -needy meals Total number of enrolled children (a+b+c) (Cannot exceed total number of enrolled children) Total number days operating (per month) Total number months operating per year ut a "Y" in each category that applies: w R Claiming Breakfast ? Claiming Morning Snack? Claiming Lunch? Claiming Afternoon Snack?. Claiming Supper? Claiming Evening Snack? Total Number of Meals Served in One Month to Eligible Children (Number of Operating Days x Average Attendance per Day) Breakfast AM Snack Lunch PM Snack Supper Evening Snack Rates July 1, 2014 - June 30, 2015 Breakfast: Free Reduced Non -Needy Lunch/Supper: Free Reduced Non -Needy Snacks: Free Reduced Non -Needy $1-62 $1.32 50.28 $2.98 $2.58 $0.28 $0.82 $0.41 $0.07 Cash -in -Lieu: $0.2475 Now the Worksheet will do the Calculations (password protected - read only) 1) Calculation to Determine Percentage Divide the number of eligible children in each category by the total number of children enrolled. a. Number free b. Number reduced price c. Number nonneedy 0 0 0 / total enrolled 0 / total enrolled 0 / total enrolled 0 Total Percentage: #QI V/Ot #D1V/01 #DIV/0l #DP.//01 HEALTH Child Care Food Program SUPPLEMENTAL BUDGET FOR SPECIAL COST ITEMS Authorization No.: Name of Organization: Mark one: ( )Original budget Amended budget For Fiscal Year Ending • Use this form to list any special cost items for which you are requesting prior written approval (per current revision of FNS Instruction 796-2) in your budget; failure to receive prior approval means that these cost items must not be charged to the CCFP. ■ Documentation to support these CCFP costs must be maintained by your organization and are subject to review prior to and after approval. • Before completing this form, refer to the guidance and instructions provided on page 4. SPECIAL COST ITEMS DOLLAR AMOUNT Administrative DOLLAR AMOUNT Operational (Food Service) L.-Special Compensation (A) Compensation to nonprofit organization's trustees, directors, officers, or family members thereof for CCFP services performed.............,......, .......,........ (B) Stipends to compensate board members for the costs of attending corporate meetings when CCFP business is conducted_ ..................... ......... .......... .......... ,-. (C) A substantial increase in the organization's level of compensation to an individual or all employees funded from CCFP monies. .. _ ... .14.“ • V•11,. ...... .. • .... ..- .. IL :Overtime, Holiday'Pay andlCompensatory-Leave .. (A) Payment of overtime, holiday pay for work performed on a non -work holiday, and compensatory leave. ......... ........ .... ........................... ......... .............. (B) incentive payments and awards exceeding $500 made to CCFP funded employees.., (C) Severance pay for CCFP funded employees when it does not constitute excess (D) Deferred compensation for CCFP funded employees when the deferral is in best interest of the CCFP (other restrictions also apply; see current FNS Instruction 796-2 (E) Amendments or modifications to approved deferralans for CCFP funded employees III. Contribuitivns and Donation Costs , :., .. Costs required to make goods or services donated to the organization usable for the CCFP (donated or volunteer labor is unallowable)..................................................... IV. Depreciation and UseAliowance E q,uip Pment and lm rovements $6,000 or more . (A) Using a different method of depreciation for space and facility other than the 30 year straight line method or a method accepted by the IRS ..... ................................... (B) For publicly owned buildings, the amount assigned as the acquisition cost (C) Unknown acquisition cost,,........................................„...... (D) Using a different method of depreciation for equipment other than the 15 year straight line method or a method accepted by the IRS ... .. .. . (E) A use allowance can be claimed but cannot exceed six and two-thirds percent of the acquisition cost... V. Direct Expensing Equipment and Other Property"$5,000 or more : " .: $ Amount (Adm.) ' $ Amount (Op.) The program's share of the cost of equipment or property purchased by the organization for use in the CCFP (typically this applies to large food service equipment see current FNS instruction 798-2 for a list of exclusions)........................................................... . Revised 8/2013 1 1-045-07 VI. Facilities and Space Costs The costs for rearrangement and alterations to facilities owned by the organization that are necessary for efficient and effective CCFP operations b.ut do not result in capital improvements ViI, Insurance (A) Costs of other insurance maintained by the organization in connection with the general activities of the CCFP when the type, extent and cost of coverage is in accordance with the general state or local government policy and sound business practices (B) Costs of insurance or contributions to any self-insurance reserve covering the risk, loss, or damage to Federal Government property to the extent that the organization is liable for such loss or damage (C) Contributions to a reserve for self-insurance to the extent that the reserve meets state insurance requirements and the type of coverage, extent of coverage and the rates and premiums that would have been allowed had insurance been purchased to cover the risks. Vill. Employee Morale, Health, and Welfare Costs and Credits (A) The cost of professional crisis intervention counseling and emergency medical care when the costs are a direct result of participation in the CCFP...... .............. . (B) Cost of current benefits provided to program employees if these benefits were provided to the same class of employees prior to participation in the CCFP (C) Cost of new or expanded benefit programs if existing benefit programs were provided to the same class of employees prior to participation in the CCFP ........... IX. Interest and Other Financial Costs (A) Stop payment charges for reimbursement payments and other CCFP disbursements, whether by check or EFT.,......... .................... ........ ......... .............:., (B) CCFP account reconciliation and analysis fees, including the allocated share of fees charged for commingled accounts.........:......,.....,.,......................,..,...,.........., (C) Interest on organizational debt incurred after 10/1/1998 for non-profit private organizations and after 10/1/1980 for public organizations, used to acquire or replace allowable CCFP equipment or other property or make allowable CCFP improvements are allowable if the following documentation requirements are met and forwarded to DOH: —a financing arrangement, which is a bona -fide arms -length transaction between unrelated parties, requires full disclosure to DOH —a financing arrangement, which is not an arms -length transaction, requires full disclosure to DOH and the Federal Regional Office X. Tier I Day Care Home Licensing Costs (up 'to"$300per :home) Costs for the following items are allowable gait if the items are necessary for unlicensed Tier I eligible day care homes to meet licensing requirements: (A) Supplies such as smoke detectors and fire extinguishers ... (B) Minor alternations such as adding handrails (C) The costs of fire and safety inspections and licensing fees. , XI. Legal Expenses and Other Professional Services (A) The sponsoring organization's cost to pursue administrative and judicial recovery of CCFP funds due from sponsored facilities when the costs are reasonable in relation to the amount of the funds due ...... ........... . ... .,... (B) The organization's costs for CCFP-related services performed by individuals who are not officers, employees or members of the organization but who are members of a particular profession or possess a particular skill,.„.. ... XII: Purchased Services for Procgram Operation — Other (Excluding Professional Services as listed above) (A) Transactions that are not arms -length and involve related parties for purchased services....... ....:.......:......,.........:............:....:.........,.... ..... (B) Maintenance and service repair contracts on CCFP equipment..................... .... (C) Ali other purchased service costs needed for CCFP operation ............... ......,........... XIII. Proposal Costs :.. $ Amount (Adm.) . $ Amount (Op.) The costs of preparing proposals for potential FNS Child Nutrition Program grants............. XIV. Membership in Civic and Other Organizations Costs of public and not -for -profit organizations memberships in civic or community organizations for CCFP funded employees; requires full disclosure to DOH and the Federal Regional Office with accompanying documentation .......................................... Revised 8/2013 2 i-045-07 XV. Meetings and Conferences The prorated share of travel and registration fees when the CCFP is only a portion of a larger child care related agenda................................,..............................,.....,....._... XVI. Management Studies The cost of studies directly related to the program that are performed by entities other thanthe organization itself........._.......................................................................... XVII. CCFP Rental Costs Special lease arrangements -- capital leases, sale -with -lease -back leases, less -than - arms -length transactions, and lease with option -to -purchase (documentation must accompanythis farm).........:................................................................................ TOTAL $ 0.00 $ 0.00 Prepared by: (Name and Title) Preparer's Signature: Date: For DOH Use Only: Approved by: Date Approved: (Program Specialist Signature) Approved by: Date Approved: (Headquarters Approver Signature) Revised 8/2013 3 1-045-07 Guidance for using the Supplemental Budget for Special Cost Items Use the following Common Special Cost Items chart to help determine whether or not you need to charge special cost items to the CCFP and complete a Supplemental Budget. Keep in mind that this is a list of common special cost items charged to the program; the Supplemental Budget for Special Cost Items form includes a complete listing of special cost items. More detailed information can be found in the current revision of FNS Instruction 796-2. Common Special Cost Items Corresponding # on Supplemental Budget Overtime pay II. A. Equipment costing more than $5,000 and which is used exclusively for the CCFP can be directly expensed; otherwise, without specific prior written approval, the cost of that item can only be recovered through "depreciation" which is approved through the annual (regular) budget approval process IV Professional and consultant services that are CCFP related: attorney costs related to administrative review, accountant (for non tax services), management consultant, nutritionist; Semi-professional services: bookkeeping services, internet/web design consultant, computer programming services XI. B. Maintenance CONTRACTS and service repair CONTRACTS on CCFP XlI. B. equipment Any purchased services such as janitorial, pest control, security, trash pick-up, etc. XII. C. How to complete the Supplemental Budget: 1. Fill in your CCFP authorization number (if one has been assigned) and your organization name. 2. Check "Original budget" if you are submitting your first CCFP budget of the fiscal year, or check "Amended budget" if you are submitting a budget amendment during the fiscal year. 3. Fill in the blank after "For Fiscal Year Ending," indicating the fiscal year to which this form applies; For example, if the applicable fiscal year is October 2013 to September 2014, you would enter 2014. 4. On the blank Supplemental Budget enclosed, indicate the dollar amount for each specific item of cost you plan to charge to the CCFP in the column titled "Dollar Amount/Administrative' or "Dollar Amount/Operational (Food Service)," whichever is appropriate for the specific item. 5. Total the amount(s) in the "Dollar Amount" column(s) and enter the total(s) on the "TOTAL" line on Page 3, 6. For sponsors of unaffiliated child care centers and sponsors of day care homes, include the reported amounts on the appropriate CCFP administrative budget schedule(s). For all other contractor types, include each "TOTAL" on your CCFP Budget form in either Food Service/Operational Costs -Other, or Administrative Costs -Other, as applicable; write in the words "special cost item(s)" on the "Describe" line of your organization's CCFP Budget. 7. The employee who completed the form must list their name and title, then sign and date. 8. Attach the Supplemental Budget form to your CCFP Budget form. Revised 8/2013 4 1-045-07 Child Care Food Program COMPENSATION PLAN FOR LABOR COSTS ©RGANIZATION NAME: AUJTH©RIZATION NO.: If your organization will not charge tabor costs to the CCFP, please write N/A (not applicable) here then skip to page 5 and complete the signature area. If your organization will charge labor costs to the Child Care Food Program (CCFP), your organization must establish and maintain a written compensation policy for every category of compensation charged/expensed to the CCFP. Labor Costs include all forms of compensation earned and ail forms of payment made either in cash or non -cash for personal services. If your organization is not charging, for example, incentive awards or severance pay, or certain benefits to the CCFP, your organization's written compensation plan does not have to address that category. The categories of labor costs are: • Salaries and wages, including rates of pay and hours of work • Taxes • Overtime, Holiday Pay and Compensatory Time • Incentive Award Payments • Fringe Benefits • Severance Pay If your organization has a personnel, human resources, or employee manual/policy; a copy of it must be submitted along with the Compensation Plan for Labor Costs. Before completing this form, refer to the instructions on the back of page 5, 1. Is regular employee compensation, such as salaries and wages, charged to the CCFP? ) No, skip to question #2. 0 YES, check policy(s) below (A, B, and/or C) if it Is the organization's policy(s) or check D and attach your own policy.. ■ A. Wage and Salary Administration and Changes in Salaries Salaries and wages of all new employees, quoted at hourly, weekly or monthly rates, are established when making an offer of employment and approved by management. Each employee's salary or wages are formally reviewed annually and adjusted based upon the results of each employee's performance appraisal. New hires, terminations, pay rate changes, voluntary payroll deductions and court -ordered payroll deductions are approved in writing by management. A copy of all such authorizations is retained in each employee's personnel file. Management promptly notifies the payroll clerk (or appropriate staff) of all hires, rate changes, dismissals and employee separations. Master personnel records are maintained of each active employee and of past employees for the prior five years and as required by the CCFP contract. Jl B. Child Care Food Program Policy for Salaries and Wages Charged to the CCFP This organization Identifies 1) position title; 2) rate of pay by the hour, week, biweekly, monthly, or yearly; and, 3) work day hours. This information is provided to the Bureau of Childcare Food Programs either as part of the CCFP Management Plan or the CCFP Budget (whichever is applicable). Revised 8/2013 Page 1 of 5 1-O48-0 r N C. Child Care Food Program Policy for Special Compensation Charged to the CCFP :, a,: Special compensation to members of nonprofit organizations, trustees, directors, associates, officers, or the immediate families thereof, for special CCFP services requires prior written approval. Stipends to compensate board members for the costs of attending corporate meetings when CCFP business is conducted require prior written approval. Any change to this written compensation plan that results in a SUBSTANTIAL increase in the organization's level of compensation to an individual or all employees funded from CCFP monies requires prior written approval. Payment of any special compensation as described in this paragraph is projected for each CCFP employee and included in the annual CCFP budget. The form titled, Supplemental Budget For Special Cost Items, must be completed and submitted with the budget. I have attached the organ€zation's policy. If including agency manual, you must list the pages that identify the policy: 2. Is employee overtime pay charged to the CCFP? 0 NO, skip to question #3. (Q YES, check the policy below (A) if that is the organization's policy or check B and attach your own policy. DA. Overtime Pay for Fair Labor Standards Act (FLSA) for Non -Exempt Personnel ;ll'; All regular employees, other than those exempted from FLSA, are entitled to overtime premium pay at the rate of time -and - a -half for all hours worked in excess of forty (40) hours in the seven (7) day period from Sunday to Saturday. Time taken off for vacation, holidays, sick leave and other excused absences is not to be considered In calculating the total hours worked. Authorization for all overtime is obtained from each employee's supervisor. In compliance with the FLSA Record Retention policy, the organization retains the following records for at least three (3) years: employee's name, home address, occupation, sex, and hours and days of work. Payment of overtime as a result of performing CCFP administrative and operational functions must be necessary and reasonable. Payment of overtime is projected for each CCFP employee and included in the annual CCFP budget. The form titled, Supplemental Budget for Special Cost Items, must be completed and submitted with the budget. I have attached the organization's policy. If including agency manual, you must list the pages that identify the policy; 3. Is compensatory time for FLSA-Exempt employees charged to the CCFP? (Note: compensatory time is paid time off In place of paid overtime. Federal and State labor laws exempt certain employees from receiving overtime compensation. Some organizations provide compensatory time for exempt employees.) Q NO, skip to question #4. 0 YES, check the policy below (A) If that is the organization's policy or check B and attach your own policy. A. Payment of Compensatory Time Policy 7%)'- All FLSA-exempt personnel receiving supervisory authorization for overtime are to record the overtime worked on their time sheets or proper documentation. For special projects or assignments, management may authorize compensatory time. If compensatory time is authorized and is charged to the CCFP, payment of compensatory time is projected for each CCFP employee and included in the annual CCFP budget. The form titled, Supplemental Budget for Special Cost Items, must be completed and submitted with the budget. ,.t,; This symbol means a Supplemental Budget for Special Cost Items is required. Revised 8/2013 Page 2 of 5 I-048-O6 0.1 B. I have attached the organization's policy. If including agency manual, you must list the pages that identify the policy: 4. Is holiday pay for employees charged to the CCFP? 0} NO, skip to question #5. 0 YES, check policy(s) below (A and/or B) if it is the organization's policy or check C and attach your own policy, A. Holiday Policy The following and any other days as determined by Management may be considered holidays. They may be granted with pay to all eligible full-time or part-time employees. +Check here if ALL holidays listed below are paid holidays that will be charged to the CCFP. If only SOME of the holidays listed below are paid holidays that will be charged to the CCFP, please mark those holidays. If needed, add any other paid holidays charged to the CCFP. 1. New Year Day -- January 1 9. Thanksgiving Day — fourth Thursday in Nov. 2. Martin Luther King Jr. Day — third Monday in Jan. 10. - Friday after Thanksgiving — fourth Friday in Nov. 3. President's Day — third Monday in Feb. 11. Christmas Eve — December 24 4. Good Friday — Friday before Easter 12, _ Christmas Day — December 25 5, Memorial Day — last Monday in May 13. 6. Independence Day — July 4 14. _ 7, Labor Day — first Monday, in. Sept, 15. — 8. Veteran's Day— November 11 16 When a holiday falls on a Saturday, the preceding Friday shall be observed as the official holiday for that year. When a holiday falls on a Sunday, the following Monday shall be observed as the official holiday. Management determines when any department or operation will be closed in observance of a holiday. Employees who work on the observed holiday shall be granted equal time off on another day elected by the employee with agreement by Management. L B. Policy Regarding Holiday Pay Charged to the CCFP Payment of a holiday for work performed on a NON -WORK holiday is projected for each CCFP employee and included in the annual CCFP budget. A non -work holiday occurs when the date of a holiday Is a staff person's regular day off. The form titled, Supplemental Budget for Special Cost Items, must be completed and submitted with the budget, Such work as a result of performing CCFP administrative and operational functions must be necessary and reasonable. C. I have attached the organization's policy. If including agency manual, .you must list the pages that identify the policy: 5. Are employee paid leave benefits charged to the CCFP? 0 NO, skip to question #6. 0 YES, check the policy below (A) If that is the organization's policy or .check. B and attach your own policy. l A. Leave Benefits for Eligible Employees Leave benefits for eligible employees may be taken after or as they are earned and at established rates that are consistent for all eligible employee's with the approval of the employee's supervisor and, where appropriate, with Management approval, Such leave benefits include, at a minimum: annual leave, sick leave, and various miscellaneous leaves, such as, military, civil, conference, educational, voting, family, disability, and bereavement. This symbol means a Supplemental Budget for Special Cost Items is required. Revised 8/2013 Page 3 of 5 1-048-06 LiB. I have attached the organization's policy. If including agency manual, you must list the pages that identify the policy: 6. Are employee insurance premiums for accident, life, death and dismemberment, disability, medical, dental, and other types of employee insurance premiums charged to the CCFP? 0 NO, sklp to question #7. (am► YES, check the policy below (A) if that Is the organization's policy or check B and attach your own policy. A. Insurance Premium Payments by the Organization for Eligible Employees Insurance premium payments for eligible employees will be paid by this organization at established rates to companies recognized by the Florida Office of Insurance Regulation and in accordance with other regulatory industry standards. Management review and approval complies with all insurance industry requirements. The organization cannot be the beneficiary on any employee insurance policy. I have attached the organization's policy. If including agency manual, you must list the pages that identify the policy: 7. Are employee retirement benefits, other types of retirement contributions, or pension plans on behalf of the employee charged to the CCFP? O NO, skip to question #8. 0 YES, check the policy below (A) if that is the organization's policy or check B and attach your own policy. A. Retirement Program Eligibility All full-time, regular employees and others meeting specific employment criteria as established by Management are eligible to participate in the retirement plan. B. I have attached the organization's policy. If Including agency manual, you must list the pages that Identify the policy: 8. Is the employer's share of employment taxes charged to the CCFP? (Note: The employer's share of Federal, State, and local employment taxes, such as Social Security withholding tax, and State unemployment taxes are allowable, but not the employee's share of such taxes.) 0 NO, skip to question #9. 0 YES, check the policy below (A) If that is the organization's policy or check B and attach your own policy. Employment Taxes Employment taxes are made In accordance with required payment schedules using forms as required by the appropriate authorities. Such taxes are recorded in the same manner (cost or accrual) and at the same time as the wage/salary benefits upon which these costs are based. I have attached the organization's policy. If including agency manual, you must list the pages that identify the policy: a : This symbol means a Supplemental Budget for Special Cost Items is required. Revised 8/2013 Page 4 of 5 1-048-06 9. Are employee incentive award payments charged to the CCFP? NO, skip to question #10. Q YES, check the policy below (A) if that is the organization's policy or check B and attach your own policy. A. CCFP Incentive payments and awards s1.�c Except for awards of minimal value ($100 or less), specific prior written approval is required for the costs of an incentive payment or award given to an employee. Payment of incentive awards is projected for each CCFP employee and included in the annual CCFP budget. The form titled, Supplemental Budget for Special Cost Items, must be completed and submitted with the budget. These costs are allowable to the extent that the employee receiving the award (cash or additional vacation leave of reasonable value) performed actual CCFP labor/services, or a CCFP employee suggestion was implemented. NOTE: Incentive payments or awards given to employees to improve performance are unallowable costs. I have attached the organization's policy, If including agency manual, you must list the pages that identify the policy: 10. Is employee severance pay charged to the CCFP? (Note: severance pay is payment in addition to regular compensation to a terminated employee). NO, complete the signature area below. 0 YES, check the policy below (A) if that is the organization's policy or check B and attach your own policy. A. Severance Pay for CCFP Funded Employees `1c This organization pays severance pay as required by our employer -employee agreement, by law, and any labor relations agreement. Management reviews each case and makes a determination. If the employee's salary is funded by the CCFP, specific prior written approval is required. Payment of severance pay (if known) is projected for a CCFP employee and included in the annual CCFP budget. The form titled, Supplemental Budget for Special Cost Items, must be completed and submitted with the budget. If termination of a CCFP funded employee is not known at the time of original budget submission, a budget amendment is subsequently submitted with the Supplemental Budget for Special Cost Items form. B. I have attached the organization's policy. If including agency manual, you must list the pages that identify the policy: t This symbol means a Supplemental Budget for Special Cost Items Is required. Signature of Authorized Representative Title Printed Name Date Revised 8/2013 Page 5 of 5 1-048-06 Instructions for Completing the COMPENSATION PLAN FOR LABOR COSTS 1. Use the worksheet below to determine which categories of Tabor costs you will be expensing/charging to the CCFP for employees funded from CCFP monies, For each category, check either yes or no after you have read the corresponding question on the Compensation Plan form. .# CATEGORIES YES NO 1 Re ular salaries and wa es 2 Regular overtime pay 3 Compensatory time (paid time off) 4 Holiday Pay Leave Benefits (annual, sick, military, civil, conference, voting, disability, bereavement, etc.) 6 Insurance premiums (accident, life, death and dismemberment, disability, medical, dental, etc.) 9 9 7 Retirement benefits, types of retirement contributions, pension plans 8 Employer's share of Federal, State, and local employment taxes (such as, Social Security and state unemployment taxes) 9 Incentive Payments and Awards 10 Severance pay 2. On the Compensation Plan form, read and mark either YES or NO for each question using your answers (above). All 10 questions must be answered. 3. For those questions marked NO, skip to the next question. 4. For EACH question marked with a YES. a. Read each policy.. b. If the policy description describes your organization's policy or is very similar to it, check the box in front of the policy.* If you wish to make an existing similar policy match your policy exactly, you may write in minor changes and initial the changes, c. If your organization's policy is significantly different from the one(s) on the Form, check the last box AND attach a copy of your policy. If you do not attach a copy of your policy, that category of labor cost is not supported by a written policy and therefore CANNOT be included in your organization's CCFP Budget, nor can your organization charge those costs to the CCFP. d. Any policy marked with a ",," indicates that a Supplemental Budget for Special Cost Items will also be required. If attaching your own policy(s), it is also possible that a Supplemental Budget for Special Cost Items will be required, depending on the content of your policy(s). 5. Complete the signature area on page 5. * Please note: On question number 4, if you check policy "A" you must also indicate the holidays that will be charged to the CCFP and are considered paid holidays (Le., employees are off and receive holiday pay or they work and receive compensatory leave time). If your policy includes all of the holidays listed, place a check in the box next to that option; if it includes only some of the holidays listed, circle all that apply, You may write in any additional paid holidays not already listed. Florida Department of Health Child Care Food Program CERTIFICATION STATEMENT REGARDING BUSINESS INTEGRITY AND PUBLICLY -FUNDED PROGRAMS General Information Two of the criteria for eligibility in the Child Care Food Program (CCFP) are that the contracting organization (institution), sponsored affiliated centers, and the principals of each business entity have not, within the past seven years, been: • convicted of any activity that indicated a lack of business integrity; and/or • declared ineligible/disqualified from any publicly -funded program because of a violation of that program's requirements, unless documentation can be provided to show that the institution and/or principal(s) has since been fully reinstated or determined eligible for the program's). "Activities indicating a lack of business integrity" include fraud, antitrust violations, embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, receiving stolen property, making false claims, obstruction of justice, tax evasion, tax fraud, failing to file tax returns, passing worthless checks, submission of false or fraudulent information to a state or federal agency, and perjury or any other activity indicating a lack of business integrity. "Convicted" means having been found guilty, with or without adjudication of guilt, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere, "Principal" means any individual who holds a management position within, or is an officer of a CCFP institution or sponsored affiliated center. "Principal" includes all members of the CCFP contractor's board of directors or the sponsored affiliated center's board of directors. Common examples of principals are the institution's owner(s), director(s), board members, and CCFP program manager. For public school districts, the principals are the school food service director, school food service accountant, school superintendent, and CCFP program manager. "Publicly -funded program" means any program or grant funded by a federal, state, or local government agency. Revised 4/2014 7-031-06 Florida Department of Health Child Care Food Program CERTIFICATION STATEMENT REGARDING BUSINESS INTEGRITY AND PUBLICLY -FUNDED PROGRAMS Organization Name: Auth. #: NOTE: The institution is responsible for collecting information from principals before completing the information and certifications below. Any organization or individual that provides false information on this form will be subject to applicable civil or criminal penalties and will be placed on the USDA National Disqualified List. List publicly -funded programs: Enter the name of each publicly -funded program participated in within the past seven years by a) the CCFP institution; and/or b) any sponsored affiliated centers; and/or c) the principals of the CCFP institution or its sponsored affiliated centers. A few examples of publicly -funded programs include Child Care Food Program, Social Services Block Grant, Child Care Development Block Grant (subsidized child care). To list more publicly -funded programs, attach separate page(s). 1. 5. 2. 6. 3. 7. 4. 8. By signing below, 1 certify that the CCFP institution, its sponsored affiliated centers, and the principals of each business entity have not been declared ineligible/disqualified from any publicly - funded program, including the CCFP, within the past seven years because of a violation of that program's requirements. (Note: If the institution and/or its sponsored affiliated center(s) and/or the principal(s) have been declared ineligible/disqualified from a publicly -funded program(s) within the past seven years, documentation to show that the disqualified entity/person has since been fully reinstated in or determined eligible for the program, including the payment of any debts owed, must be attached to this form.) By signing below, I certify that the CCFP institution, its sponsored affiliated centers, and the principals of each business entity have not been convicted within the past seven years of any activity that indicated a lack of business integrity (as defined above). Signature of Chairman of the Board, Executive Director, Date President, Majority Owner, or Delegated Authority Printed Name of Chairman of the Board, Executive Director, Title President, Majority Owner, or Delegated Authority Revised 4/2014 2 1-031-06