INSTRUCTIONS
If you are submitting the claim via the WEB, you do not need to send a claim form to the Department of
Education. However, you must retain the original on file with the Authorized Representatives signature. This
information should cover activities during one calendar month; however, you may include no more than nine operating days of the
month before the first full month of operation and/or no more than nine days of the month after the last full month of operation.
Enter the sponsor name, agreement number, month/year claimed and whether this is an original or a revised claim.
Enter number of operating days this claim period.
FOR CAMPS ONLY, Enter the monthly average eligible free and reduced children. (Add weekly eligible free and reduced and divide
by the number of weeks served in the month. EX: (54 + 75 + 35 + 66) / 4 = 58 )).
Enter the number of sites for this claim period.
Enter the average daily attendance. Compute by adding the total number of eligible children served each day by all sites to get a
cumulative total number of eligible children served for the claim period, and dividing by the number of days of operation for the same
claim period.
Enter the total number of reimbursable breakfasts for eligible children (1
st
meal).
Enter the total number of reimbursable breakfasts for eligible children (2
nd
meal).
Enter the total number of reimbursable lunches for eligible children (1
st
meal).
Enter the total number of reimbursable lunches for eligible children (2
nd
meal).
Enter the total number of reimbursable suppers for eligible children (1
st
meal).
Enter the total number of reimbursable suppers for eligible children (2
nd
meal).
Enter the total number of reimbursable snacks for eligible children (1
st
meal).
Enter the total number of reimbursable snacks for eligible children (2
nd
meal).
Enter the total number of non-reimbursable camp meals.
Enter the total number of program adult meals.
Enter the total number of non-program adult meals.
Enter all food costs including milk. Such costs shall include, in addition to the purchase price, the cost of processing, distributing,
transporting, storing, or handling of any purchased or donated food including USDA donated commodities. (DO NOT INCLUDE the
value of donated food.)
For vended sites enter the total invoices of the meals under Contracted Food Costs.
Enter the Direct Labor costs. That includes all wages earned in connection with the food preparation, delivery and service. Include
costs incurred during the monthly covering payroll deduction for social security, withholding tax, insurance, retirement, etc., as well as
employer’s contributions during the month for employee benefits. (DO NOT INCLUDE ADMINISTRATIVE COSTS.)
Enter operating costs for rent/utilities, non-food supplies (cleaning materials, paper plates, plastic eating utensils, etc.) and Equipment
Rental costs in the appropriate box.
Enter the total operating costs.
Enter the administrative costs related to planning, organizing and managing the program, printing, mailing, phone costs, cost of office
supplies, transportation, indirect costs and any costs for audits.
Enter each of the line item administrative costs in the appropriate box.
Enter total amount of funds received for food service operations from individual donations. Include state and local contributions,
payments for adult meals, and reimbursement from other Federal programs. (DO NOT INCLUDE “start-up funds”, “advance
payments”, and “monthly reimbursement payments” from this USDA program, or loans to the program.)
Enter total amount of funds received for food service administration from individual donations, state and local contributions. (DO NOT
INCLUDE “start-up funds”, “advance payments”, and “monthly reimbursement payments” from this USDA program, or loans to the
program.)
