This form must be completed and submitted annually by Nov. 20. State agencies must report the information on this form annually for each SFA with schools operating the National School Lunch Program (NSLP) and/or the School Breakfast Program (SBP). All SFAs, including SFAs with all schools exempt from verification requirements, must complete applicable sections. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it contains a valid OMB control number. The valid OMB number for this collection is 0584-0026. The time required to complete this information collection is 45 minutes per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. Respondent Information Name: Phone Number: Email: State Agency Name: SFA ID#: Type of SFA: Public Nonprofit/PrivateSchool Year:From: 20 To: 20 SFA Name: Acadia Academy Acton School Department Airline CSD Alexander School Department Andover Public Schools Appleton Public Schools Arthur R. Gould School - LCYDC Athens Public Schools Auburn School Department Augusta Public Schools Baileyville School Department Bangor School Department Bar Harbor School Department Beals School Department Becket Family of Services Biddeford School Department Blue Hill School Department Boothbay-Boothbay Hbr CSD Brewer School Department Bristol Public Schools Brooklin School Department Brooksville School Department Brunswick School Department Calais School Department Cape Elizabeth School Department Carleton Project Castine School Department Caswell School Department Charlotte School Department Cherryfield Public Schools Community Regional Charter Connor Consolidated School Cutler School Department Dayton Public Schools Dedham School Department Deer Isle-Stonington CSD East Machias School Department East Millinocket School Department East Range CSD Easton School Department Eastport School Department Ecology Learning Center Edgecomb School Department Edmunds Consolidated School Ellsworth Public Schools Erskine Academy Eustis Public Schools Falmouth School Department Fayette School Department Five Town CSD Foxcroft Academy Fryeburg Academy Georgetown School Department Glenburn Public Schools Glenwood Public Schools Glenn Stratton Learning Center Good Shepherd Parish Schools Gorham School Department Great Salt Bay CSD Greenbush School Department Greenville School Department Hancock Public Schools Harmony School Department Hermon School Department Holy Cross School - South Portland Holy Savior School Hope School Department Indian Island Indian Township Islesboro School Department Jefferson Public Schools Jonesboro School Department Jonesport School Department Kids Peace New England Kingman Elementary School-EUT Kittery School Department Lamoine Public Schools Lee Academy Lewiston School Department LimestoneLincoln Academy Lincoln-Region 3 Lincolnville School Department Lisbon School Department Long Island School Department Machias School Department Machiasport School Department Madawaska School Department Maine Academy of Natural Sciences Maine Arts Academy Maine Central Institute ME Educational Ctr for the Deaf & Hard of Hearing Medway Public Schools Milford School Department Millinocket School Department Moosabec CSD Mount Desert School Department Mount Merici Academy Mountain View Youth Dev Ctr MSAD 27 MSAD 46 MSAD 76 Mt Desert CSD New Beginnings Nobleboro Public Schools Northport Opportunity Training Center Orrington School Department Otis School Department Pembroke School Department Penobscot School Department Perry School Department Pleasant Point Portland Public Schools Princeton School DepartmentRockland RSU 01 - Lower Kennebec RSU RSU 02- Kennebec Intra-District RSU 03/MSAD 03 RSU 04 RSU 05 RSU 06/MSAD 06 RSU 08/MSAD 08 RSU 09/MSAD 09 RSU 10 RSU 11/MSAD 11 RSU 12 RSU 13 RSU 14 Raymond/Windham RSU 15/MSAD 15 RSU 16 RSU 17/MSAD 17 RSU 18 RSU 19 RSU 20 RSU 21 RSU 22/MSAD 22 RSU 23 RSU 24 RSU 25 RSU 26 RSU 28/MSAD 28 RSU 29/MSAD 29 RSU 30/MSAD 30 RSU 31/MSAD 31 RSU 32/MSAD 32 RSU 33/MSAD 33 RSU 34 RSU 35/MSAD 35 RSU 37/MSAD 37 RSU 38 RSU 39 RSU 40/MSAD 40 RSU 41/MSAD 41 RSU 42/MSAD 42 RSU 44/MSAD 44 RSU 45/MSAD 45 RSU 49/MSAD 49 RSU 50 RSU 51/MSAD 51 RSU 52/MSAD 52 RSU 53/MSAD 53 RSU 54/MSAD 54 RSU 55/MSAD 55 RSU 56 RSU 57/MSAD 57 RSU 58/MSAD 58 RSU 59/MSAD 59 RSU 60/MSAD 60 RSU 61/MSAD 61 RSU 63/MSAD 63 RSU 64/MSAD 64 RSU 67 RSU 68/MSAD 68 RSU 70/MSAD 70 RSU 71 RSU 72/MSAD 72 RSU 73 RSU 74/MSAD 74 RSU 75/MSAD 75 RSU 78 RSU 79/MSAD 01 RSU 80/MSAD 04 RSU 82/MSAD 12 RSU 83/MSAD 13 RSU 84/MSAD 14 RSU 85/MSAD 19 RSU 86/MSAD 20 RSU 87/MSAD 23 RSU 88-/SAD 24 Rumford Group Home Saco Public Schools Sanford School Department Scarborough School Department Sedgwick School Department Snow Pond Charter School South Bristol Public Schools South Portland Public Schools Southport Public Schools Southwest Harbor School Department Spurwink School Inc. St. George Public Schools St. Thomas School Surry Public Schools Sweetser Children's Services Tremont School Department Trenton School Department Vanceboro School Department Vassalboro School Department Veazie Public Schools Washington Academy Waterville Public Schools Wayfinder Schools Wells-Ogunquit CSD Wesley Public Schools West Bath Public Schools Westbrook School Department Whiting School Department Winslow Schools Winthrop Public Schools Wiscasset Public Schools Woodland School Department Yarmouth Schools York School Department Youth Alternatives Inc. SFA City: SFA Zip Code: Section 1: Total Schools, Residential Child Care Institutions (RCCIs) and Enrolled Students. All SFAs must report Section 1 Subsection A. Number of schools or institutions B. Number of students 1-1: Total schools (Do not include RCCIs) 1-1: Total schools (Do not include RCCIs). A. Number of schools or institutions 1-1: Total schools (Do not include RCCIs). B. Number of students 1-2: Total RCCIs (Do not include schools counted in 1-1) 1-2: Total RCCIs (Do not include schools counted in 1-1). A. Number of schools or institutions 1-2: Total RCCIs (Do not include schools counted in 1-1). B. Number of students 1-2a: RCCIs with day students (Report only day students in 1-2a, column B) 1-2a: RCCIs with day students (Report only day students in 1-2a, column B). A. Number of schools or institutions 1-2a: RCCIs with day students (Report only day students in 1-2a, column B). B. Number of students 1-2b: RCCIs with no day students 1-2b: RCCIs with no day students. A. Number of schools or institutions 1-2b: RCCIs with no day students. B. Number of students Section 2 SFAs with schools operating alternate provisions. Only SFAs with alternate provisions must report Section 2 Subsection A. Number of schools and institutions B. Number of students 2-1: Operating provisions 2/3 in a base year for NSLP and SBP 2-1: Operating provisions 2/3 in a base year for NSLP and SBP. A. Number of schools or institutions 2-1: Operating provisions 2/3 in a base year for NSLP and SBP. B. Number of students 2-2: Operating provisions 2/3 in a non-base year for NSLP and SBP 2-2: Operating provisions 2/3 in a non-base year for NSLP and SBP. A. Number of schools or institutions 2-2: Operating provisions 2/3 in a non-base year for NSLP and SBP. B. Number of students 2-2a: Provision 2/3 students reported as free in a non-base year 2-2a: Provision 2/3 students reported as free in a non-base year. A. Number of schools or institutions 2-2a: Provision 2/3 students reported as free in a non-base year. B. Number of students 2-2b: Provision 2/3 students reported as reduced price in a non-base year 2-2b: Provision 2/3 students reported as reduced price in a non-base year. A. Number of schools or institutions 2-2b: Provision 2/3 students reported as reduced price in a non-base year. B. Number of students 2-3: Operating the community eligibility option 2-3: Operating the community eligibility option. A. Number of schools or institutions 2-3: Operating the community eligibility option. B. Number of students 2-4: Operating other alternatives for NSLP and SBP 2-4: Operating other alternatives for NSLP and SBP. A. Number of schools or institutions 2-4: Operating other alternatives for NSLP and SBP. B. Number of students 2-5: Operating an alternate provision(s) for only SBP or only NSLP 2-5: Operating an alternate provision(s) for only SBP or only NSLP. A. Number of schools or institutions 2-5: Operating an alternate provision(s) for only SBP or only NSLP. B. Number of students Section 3 Students approved as free eligible, not subject to verification. All SFAs must report Section 3 or check box 3-1 if applicable Subsection B. Number of free students 3-1: Check this box only if all schools and/or RCCIs in the SFA were not required to perform direct certification with SNAP (i.e., non-baseyear provision 2/3 for all schools) B. Number of free students 3-2: Students directly certified through Supplemental Nutrition Assistance Program (SNAP): Do not include students certified with SNAP through the letter method 3-2: Students directly certified through Supplemental Nutrition Assistance Program (SNAP): Do not include students certified with SNAP through the letter method. B. Number of free students 3-3: Students directly certified through other programs: Include those directly certified through Temporary Assistance for Needy Families (TANF), Food Distribution Program on Indian Reservations (FDPIR), or Medicaid (if applicable); those documented as homeless, migrant, runaway, foster, Head Start, Pre-K Even Start, or non-applicant but approved by local officials. Do not include SNAP students already reported in 3-2 33-3: Students directly certified through other programs: Include those directly certified through Temporary Assistance for Needy Families (TANF), Food Distribution Program on Indian Reservations (FDPIR), or Medicaid (if applicable); those documented as homeless, migrant, runaway, foster, Head Start, Pre-K Even Start, or non-applicant but approved by local officials. Do not include SNAP students already reported in 3-2. B. Number of free students 3-4: Students certified categorically free eligible through SNAP letter method: Include students certified for free meals through the family providing a letter from the SNAP agency 3-4: Students certified categorically free eligible through SNAP letter method: Include students certified for free meals through the family providing a letter from the SNAP agency. B. Number of free students Section 4 Students approved as free or reduced-price eligibleb through a household application. All SFAs collecting applications must report Section 4 Subsection A. Number of applications B. Number of students 4-1: Approved as categorically free eligible: Based on those providing documentation (e.g., a case number for SNAP, TANF, FDPIR on an application 4-1: Approved as categorically free eligible: Based on those providing documentation (e.g., a case number for SNAP, TANF, FDPIR on an application. A. Number of applications 4-1: Approved as categorically free eligible: Based on those providing documentation (e.g., a case number for SNAP, TANF, FDPIR on an application. B. Number of students 4-2: Approved as free eligible: Based on household size and income information 4-2: Approved as free eligible: Based on household size and income information. A. Number of applications 4-2: Approved as free eligible: Based on household size and income information. B. Number of students 4-3: Approved as reduced price eligible: Based on household size and income information 4-3: Approved as reduced price eligible: Based on household size and income information. A. Number of applications 4-3: Approved as reduced price eligible: Based on household size and income information. B. Number of students T1: Total free eligible students reported T2: Total reduced price eligible students reported Section 5 All SFAs must report Section 5 or check box 5-1 if applicable. 5-1: Check this box if all schools and/or RCCIs are exempt from verification (see instructions for list of exemptions). If 5-1 is checked, no further reporting in Section 5 is required 5-2: Was verification performed and completed? Yes, completed by November 15 Yes, completed after November 15 No, verification was not performed or the process was not completed5-3: Type of verification process used 1. Standard (Lesser of 3% or 3,000 error-prone 2. Alternate one (Lesser of 3% or 3,000 selected randomly) 3. Alternate two (Lesser of 1% or 1,000 error-prone applications plus lesser of one-half of one percent or 500 applications with SNAP/TANF/FDPIR case numbers)If 1 or 3 is checked in 5-3, report 5-4. If 2 is checked in 5-3, enter ‘N/A’ in 5-4 5-4: Total error prone applications: Report all applications as of October 1 considered error-prone 5-5: Number of applications selected for verification sample All SFAs must report 5-7 or check box 5-6 if applicable. 5-6: Check this box if direct verification was not conducted in the SFA (i.e., not one of the schools and/or RCCIs in the SFA performed direct verification)If 5-6 is checked, skip 5-7 Report if free and/or reduced price eligibility is confirmed through direct verification with SNAP/TANF/FDPIR/MEDICAID as of November 15 A. Number of Applications B. Number of students 5-7: Confirmed through direct verification 5-7: Confirmed through direct verification. A. Number of Applications 5-7: Confirmed through direct verification. B. Number of students 5-8: Results of Verification by Original Benefit Type For each original benefit type (A, B, & C), report the number of applications and students as of November 15th for each result category (1, 2, 3, & 4). Do not include students and applications already reported in 5-7A or 5-7B. A. Free - Categorically Eligible Certified as free based on SNAP/TANF/FDPIR documentation (e.g., case number) on application Result Category a. Applications b. Students 1. Responded, no change 1. Responded, no change. a. Applications 1. Responded, no change. b. Students 2. Responded, changed to reduced price 2. Responded, changed to reduced price. a. Applications 2. Responded, changed to reduced price. b. Students 3. Responded, changed to paid 3. Responded, changed to paid. a. Applications 3. Responded, changed to paid. b. Students 4. Not responded, changed to paid 4. Not responded, changed to paid. a. Applications 4. Not responded, changed to paid. b. Students B. Free - Income Certified as free based on income/household size application Result Category a. Applications b. Students 1. Responded, no change 1. Responded, no change. a. Applications 1. Responded, no change. b. Students 2. Responded, changed to reduced price 2. Responded, changed to reduced price. a. Applications 2. Responded, changed to reduced price. b. Students 3. Responded, changed to paid 3. Responded, changed to paid. a. Applications 3. Responded, changed to paid. b. Students 4. Not responded, changed to paid 4. Not responded, changed to paid. a. Applications 4. Not responded, changed to paid. b. Students C. Reduced Price - Income Certified as reduced price based on income/household size application Result Category a. Applications b. Students 1. Responded, no change 1. Responded, no change. a. Applications 1. Responded, no change. b. Students 2. Responded, changed to free 2. Responded, changed to free. a. Applications 2. Responded, changed to free. b. Students 3. Responded, changed to paid 3. Responded, changed to paid. a. Applications 3. Responded, changed to paid. b. Students 4. Not responded, changed to paid 4. Not responded, changed to paid. a. Applications 4. Not responded, changed to paid. b. Students VC-1: Total questionable applications verified for cause (Enter N/A if not applicable) - Report the number of applications as of November 15 verified for cause in addition to the verification requirement Submit