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[]
[null,"SFSP Home Delivery Certification Statement\n"]
[null,"PART I: Preliminary Information"]
[null,"Organization Name:"]
[null,"Agreement Number:"]
[null,"PART II: Home Delivery "]
[null,"Number of Actual Sites using Home Delivery:"]
[null,"Home Delivery Agreement:\nBy clicking \"yes\" below, I certify that as a CACFP/SFSP Program operator, I will:\n(1) first obtain written consent from households of eligible & enrolled children and/or adult participants that the household wants to receive delivered meals; \n(2) confirm and maintain documentation supporting the eligibility and number of children being served;  \n(3) confirm the household's current contact information to ensure meals are delivered to the correct location;                                                   (4) confirm and maintain documentation supporting the number of meals delivered to each home; \n(5) ensure not to exceed the maximum number of meals per child per day; and\n(6) protect the confidentiality of participants and their households throughout the process in accordance with confidentiality and disclosure provisions in the National School Lunch Act and 7 CFR 225.15(f)-(l)\n\nAdditionally, I certify I will notify households if their contact information will be shared with any external organization. Households also must have a way of notifying the sponsor of the need for individual substitutions due to medical or other special dietary needs. (Note: Written consent may be issued by hard copy documentation, e-mail, or other electronic means and must be given by the participant's parent or guardian.)  "]
[]
[]
[]
[null,"PART II B: Home Delivery Participant Eligibility (Non-SFA Sponsors must mark yes to one of the following)"]
[null,"1. Memorandum of Understanding (MOU) with SFA"]
[null,"The organization has secured written MOUs with an SFA to use the SFA's student data to establish the eligibility for meal recipients and certifies that no meals will be delivered to homes that are not supported by the eligiblity data obtained from the SFA. The organization will maintain the MOU and provide the MOU upon request."]
[null,null,null,null,null,"Yes     ","   No"]
[null,"2. Income Eligibility Statements"]
[null,"The organization has secured Income Eligibility Statements (IES forms) to identify eligibile children and certifies that meals will only be delivered to households 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 III: Certification Statement"]
[null,"I certify/attest the information contained within this entire document 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 IV: Signature"]
[null,"Electronic Signature of Program Contact or Authorized Representative: ",null,null,null,null,null,"/s/   [TYPE YOUR NAME HERE]"]