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Updated Forms


The following forms have been updated for Fiscal Year 2013. Hard copies of these forms can be requested by calling 1-877-618-7262.

The table below lists the name of each form, the purpose of each form, and the applicable program type in which each form is required to be used:

Form

Purpose

Child Care

At Risk

Adult
Day Care

Emergency Shelter

Adult Day Care Enrollment Form

You must document enrollment information for each participant in your institution. This is an example of the type of format that could be used to document enrollment.

 

 

X

 

Adult Day Care Income Eligibility Form and Instructions

This form must be reproduced and distributed annually to each participant’s household and used to classify each participant for free, reduced, and paid.

 

 

X

 

Adult Day Care Letter to Households

This form must be reproduced and distributed annually to each participant’s household with the Income Eligibility Form and Instructions.

 

 

X

 

Building for the Future Flier

The flyer must be reproduced and distributed annually along with the Income Eligibility and Enrollment Form.

X

 

 

X

CACFP Appeal Rights

Information on the CACFP Appeal Procedures for your reference.

X

X

X

X

CACFP Rates of Reimbursement (Effective July 1, 2012)

New rates of reimbursement effective July 1, 2012.

X

X

X

X

Child Care Income Eligibility and Enrollment Form Combined

This form must be reproduced and distributed annually to each participant’s household and used to classify each participant for free, reduced, and paid. NOTE: You must document enrollment information for each child enrolled at your institution; you may use the combined form or you may still use a separate enrollment form for each child. 

X

 

 

 

Child Care Letter to Households

This form is to be reproduced and distributed annually to each child’s household with the Income Eligibility and Enrollment Form.

X

 

 

 

Civil Rights Data Collection Form

This form is to be used to document your annual Civil Rights data collection.  NOTE: This form does NOT need to be submitted to VDH; instead, keep the form on file at your institution with your CACFP records.

X

X

X

X

Income Eligibility Guidelines (Effective July 1, 2012)

New Income Eligibility Guidelines for classifying each participant.  These guidelines are effective July 1, 2012.  NOTE:  Participants classified on or after July 1, 2012 should be classified using these income guidelines. 

X

 

X

 

WIC Factsheet

The flyer must be reproduced and distributed each year to each participant.

X

X

 

X



Additional Forms for Sponsors:

Form

Purpose

Child Care

At Risk

Adult
Day Care

Emergency Shelter

Child Care
Monitoring Form

Reproduce this form and use to document monitoring visits. Completed copies are retained at the institution’s office.

X

 

 

 

At Risk
Monitoring Form

Reproduce this form and use to document monitoring visits. Completed copies are retained at the institution’s office.

 

X

 

 

Adult Day Care
Monitoring Form

Reproduce this form and use to document monitoring visits. Completed copies are retained at the institution’s office.

 

 

X

 

Emergency Shelter
Monitoring Form

Reproduce this form and use to document monitoring visits. Completed copies are retained at the institution’s office.

 

 

 

X

 

 

Last Updated: 01-23-2013

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