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[null,"Conditional Non-Congregate Certification and Eligibility Determination Statement"]
[null,"PART I: Preliminary Information"]
[null,"Sponsor Name:"]
[null,"Agreement Number:"]
[null,"Number of Conditional Non-Congregate Sites:"]
[null,"PART II: Conditional Non-Congregate Certification and Eligibility Determination Methods"]
[null,"      The sponsor will operate conditional non-congregate sites and will collect information to determine children's Program eligibility to support its claim for reimbursement as per 7 CFR 225.14(d)(7), 7 CFR 225.16(b)(5)(iv), and 7 CFR 225.9(d)(11). The sponsor will only claim meals served to children whose eligibility for Program meals is documented."]
[]
[]
[null,"1. Individual Child Eligibility Information from School Data"]
[null,"The organization is utilizing school data to establish eligibility for each child.  If a non-SFA, the organization has secured written agreement or a Memorandum of Understanding (MOU) with a SFA to use the SFA's student data to establish the eligibility for meal recipients and certifies that meals will only be claimed for children that qualify as free or reduced based upon supporting eligibility data obtained from the SFA. The organization will maintain the supporting individual school data, the MOU (if applicable), and provide the documentation upon request. In addition, the organization certifieds."]
[null,null,null,null,null,"Yes     ","   No"]
[null,"2. Income Eligibility Statements"]
[null,"The organization has secured Income Eligibility Statements (IES forms) to identify eligible children and certifies that meals will only be claimed for children that qualify as free or reduced. The organization will maintain all IES forms and provide the forms upon request. "]
[null,null,null,null,null,"Yes     ","   No"]
[null,"PART II B: Conditional Non-Congregate Certification Statement"]
[null,"I certify/attest to the statements in Part II."]
[null,null,null,null,null,"Yes     ","   No"]
[null,"PART II C: Signature"]
[null,"Electronic Signature of Program Contact or Authorized Representative: ",null,null,null,null,null,null,"/s/   [TYPE YOUR NAME HERE]   [TYPE THE DATE HERE]  "]
[]
[]
[null,"Part III. Conditional Non-Congregate Pricing Policy Statement"]
[null,"Per 7 CFR 225.6(i)(4) and 7 CFR 225.6(i)(7)(ii), for conditional non-congregate sites, sponsors may charge non-Program eligible children for meals served under the SFSP.  Regulation at 7 CFR 225.6(f)(1)(iii) requires sponsors to include a policy statement with the below information when electing to charge non-Program eligible children for SFSP meals at conditional non-congregate sites."]
[]
[null,"At conditional non-congregate sites, the sponsor will charge non-Program eligible children for SFSP meals. If yes, complete the policy statement information below."]
[null,null,null,null,null,"Yes     ","   No"]
[null,"Provide below a description of the method to be used in accepting applications from families for Program meals that ensures that households are permitted to apply on behalf of children who are members of households receiving SNAP, FDPIR, or TANF benefits using the categorical eligibility procedures described in 7 CFR 225.15(f)."]
[]
[null,"Provide below a description of the method to be used for collecting payments from children who pay the full price of the meal while preventing the overt identification of children receiving a free meal."]
[]
[null,"         The sponsor assures that all children are served the same meals and that there is no discrimination in the course of the food service."]
[null,"         The eligibility standards will conform to the Secretary's family size and income standards for reduced price school meals."]
[null,"         The sponsor assures it will establish hearing procedures for families requesting to appeal a denial of an application for free meals.  These procedures will adhere to the requirements in 7 CFR 225.6(f)(2)."]
[null,"         The sponsor assures if a family requests a hearing, the child will continue to receive free meals until a decision is rendered."]
[null,"         The sponsor assures there will be no overt identification of free meal recipients and no discrimination against any child on the basis of race, color, national origin, sex (including gender identity and sexual orientation), age, or disability."]
[null,"         The sponsor will submit its hearing procedures statement to GA DECAL."]
[null,"PART III B: Certification Statement"]
[null,"I certify/attest the information contained within this Conditional Non-Congregate Pricing Policy Statement is true and correct to the best of my ability and that intentionally listing false or inaccurate information and/or failure to notify DECAL when the information contained in this document changes, may result in the denial of a claim(s) for reimbursement and/or termination and disqualification of the organization, its responsible principals and/or individuals from participation the in CACFP, SFSP, or any other Child Nutrition Program (CNP)."]
[null,null,null,null,null,"Yes","No"]
[null,"PART III C: Signature"]
[null,"Electronic Signature of Program Contact or Authorized Representative: ",null,null,null,null,null,null,"/s/   [TYPE YOUR NAME HERE]                     [TYPE THE DATE HERE]  "]