FFVP CFD Pilot - Local

Evaluation of the Canned, Frozen, or Dried Fruits and Vegetables Pilot Project in the FFVP

Appendix D3 Prototype for FFVP Monthly Reimbursement Form

OMB Control No: 0584-XXXX

Expiration date: XX/XX/XXXX

FRESH FRUIT AND VEGETABLE

PROGRAM (FFVP)

Monthly Reimbursement Form

Prototype

Name of School: ________________________________________________________

Address: ______________________________________________________________

Name of District: ________________________________________________________

Agreement Number ___________________________

SCHOOL YEAR: _____________

SPECIFY FISCAL YEAR FUNDS: _______________

CLAIM INFORMATION:

Month/Year ______________

Number of Days of Operation in Report Month: ________________

OPERATING COSTS

Please itemize expenses for operating costs

-- Fruits/Vegetables $_________________

-- Labor (ONLY for preparation and service of $_________________

Fruits & Vegetables)

-- Small supplies/other $_________________

TOTAL OPERATING COSTS $_________________

ADMINISTRATIVE COSTS $_________________

Please itemize expenses for operating costs

Equipment, leasing, labor such as; planning, ordering, reporting, tracking, inventory, etc. total limited to 10% of grant**

SIGNATURE

Food Service Director ______________________________ Date_________________

(Please print name) ___________________________Phone#___________________

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

OPERATING COSTS: Product Description	Total Cost
Fruits
Sub-total fruits:
OPERATING COSTS: Product Description	Total Cost
Vegetables
Sub-total vegetables
OPERATING COSTS: Product Description	Total Cost
--SMALL SUPPLIES/OTHER: Please itemize (Small supplies -- e.g. napkins, paper plates, utensils, bowls, pans, other items such as low-fat dips)
ADMINISTRATIVE COSTS: please itemize (costs such as equipment purchases, leasing and labor cost not related to the preparation and serving of fruits and vegetables; labor includes but is not limited to planning, ordering, writing menus, reporting, billing, tracking, inventory, etc. Total administrative costs are limited to 10% of the grant.	Total Costs
Sub-total Administrative Costs

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