The following instructions were prepared for sponsors that participate only in the School Nutrition Program (SNP) Special Milk Program. Use form CNFS 71-5 and complete items 1 through 15 (See Appendix A-9 for a sample claim form). Sponsors who are approved to participate solely in the Special Milk Program should complete only those items addressed in these instructions. All other items on the claim do not apply.
Enter program information for only one claim month in Items 1 through 15. This information should cover activities during one calendar month, with the exception of the beginning and the end of the school year. For these periods, you may include up to ten operating days within the month of August on the September claim or up to ten operating days within the month of June on the May claim.
An error or omission on any of the following items will cause a delay in processing a sponsor’s claim and the receipt of reimbursement.
Part I - Monthly Reporting (Complete Items 1-15)
| Item | Description |
|---|---|
1 |
Agreement Number, Name, and Address: Place printed labels in the space provided (upper right-hand corner) on the original form and one copy. Use only those labels provided to the sponsor for use on the claim form CNFS 71-5. If you deplete the sponsor’s supply of labels, type or print the sponsor’s agreement number, name, and address in the spaces provided. If more labels are needed, contact CNFS. |
2 |
Month/Year: Enter the two-digit month and four-digit year that the claim covers, not the month that the claim is prepared. The month and the year must be reported numerically as shown in the following examples: December 2003 = l | 2 2 | 0 | 0 | 4 January 2004 = 0 | 1 2 | 0 | 0 | 5 Note: A sponsor may claim reimbursement only for those months indicated on the sponsor’s approved Annual Participation Statement. |
3 |
Claim Type: Mark the appropriate box that applies:
Note: If a correction to an original claim has been requested by the Department of Education, the claim is still marked as an original (box a). Please write the word “correction” at the top of the claim form. |
4 |
Adjustment Number: Do not complete. This item is for state use only. |
5 |
Reason Code: Do not complete. This item is for state use only. |
6 |
Number of Children Approved to Receive Free Milk: Enter the number of enrolled children who have approved eligibility applications on file for free milk as defined in item 15E. An actual count must be made each month. |
7 |
Do not complete. This item applies to meal programs only. |
8 |
Number of One-half Pints of Fluid Milk Purchased This Month: Enter the number of half pints of fluid milk purchased during the claim month, including whole milk, chocolate milk, low-fat milk, skim milk, buttermilk, or bulk milk. Bulk milk or milk purchased in one-third quart containers must be converted to one-half pints. Do not include milk shakes or malts. Refer to Appendix A-6 (CNFS 71-21) to calculate the conversions. |
9 |
Total Cost of Fluid Milk Purchased This Month: Enter the cost of the fluid milk purchased during the month as reported in item 8. Do not include the cost of other items that could be on the sponsor’s dairy invoice, such as ice cream, milk shakes, and so forth. Only report the cost paid to the vendor after discounts or rebates, if any. Do not add transportation costs. Report whole dollars only. Do not report cents. Note: All milk sponsors must complete both items 8 and 9, even if free milk is not claimed. |
10 |
Do not complete. This item applies to Meal Supplement Program sponsors only. |
11 |
Do not complete. This item applies to Meal Supplement Program sponsors only. |
12 |
Do not complete. This item applies to National School Lunch sponsors only. |
13 |
Do not complete. This item applies to Basic Breakfast Program sponsors only. |
14 |
Do not complete. This item applies to Especially Needy Breakfast Program sponsors only. |
15 |
Column A, Authorized Sites Participating: Enter the number of authorized schools or sites participating in the Special Milk Program during the month. The number entered may not exceed the number of schools or sites authorized on the Annual Participation Statement or the number of sites subsequently authorized through a Site Change Request Form. Column B, Enrollment: Enter the total number of children enrolled at each site that participates in the Special Milk Program as of the last day of the month. Column C, Number of Operating Days: Enter the number of days in the claim month when milk was served at any authorized site. Column D, Paid Special Milk Served: Enter the number of one-half pints of fluid milk served to children who are not eligible for free milk. If one-third quarts are served free, only the first one-half pint of each serving can be claimed as free milk served (column 15E). The remaining portion of the one-third quarts must be claimed as paid milk served (column 15D). Refer to Appendix A-6 for conversion to one-half pints. Do not include milk served to adults. Note: This item applies only to sponsors serving free milk as defined in item 15E. Do not report paid milk if your agency is a non-pricing sponsor or a pricing sponsor that does not collect eligibility applications. Do not include milk served to adults. See Appendix A-7 (CNFS 71-23) to calculate the percentage of milk served to children. Column E, Free Special Milk Served: Enter the number of one-half pints of fluid milk served to children eligible for free milk. Free milk should be claimed only when there is an approved eligibility application on file and a Policy Statement for Free Milk has been filed with the CDE.
Column G, Total Special Milk Served: Include the total number of one-half pints of fluid milk served to children under the Special Milk Program. This total must equal the sum of paid milks served (column D) and free milks served (column E). |
Certification: Before submitting a sponsor’s claim, be sure to complete this section. Include the name and telephone number of the person preparing the claim, the preparation date, and the original signature of an authorized agency official, title, and date. The signature of the authorized official must be original and in ink. Only original signatures will be accepted.
A sponsor’s claim will be returned for correction if it is not properly completed. Place an original signature on the claim before mailing the claim to avoid delays in the sponsor’s reimbursement. The agency’s authorized official signing the claim is responsible for reviewing and analyzing meal counts to ensure accuracy.
Special Note: An adjusted claim for reimbursement completely voids all the previously submitted data for the same claiming period. Therefore, when submitting an adjustment, the sponsor must report all data whether there has been a change or not.
If you would like to determine the federal and state reimbursement earned for the month, complete the Monthly Reimbursement Calculation Worksheet, Appendix A-5. Do not submit the worksheet with the sponsor’s claim; it is for your reference only.
