PI-1409 Claim Worksheet for National School Lunch ...
|[pic] |Wisconsin Department of Public Instruction |INSTRUCTIONS: Use this form as a worksheet and submit the claim |
| |CLAIM WORKSHEET FOR SMP (Special Milk Program) |information via the internet within 60 calendar days from the last day of |
| |PI-1409-NS-SMP (Rev. 11-22) |the claim month. Only submit this completed paper claim form if it is |
| | |older than 60 calendar days from the last day of the claim month. Keep a |
| | |copy of this completed form for your files. If submitting a paper claim |
| | |form, send to: |
| | |WISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION |
| | |ATTN: JACQUE DARROW |
| | |FEDERAL AND STATE GRANTS PROGRAM |
| | |PO BOX 7841 |
| | |MADISON, WI 53707-7841 |
| | |jacqueline.darrow@dpi. |
|Prevailing legislation requiring collection of this data: 7 CFR, Part 210, Part 215, | |
|and Part 220. | |
|Claims submitted more than 60 days after the end of the claiming month cannot be paid| |
|unless a onetime exception (PI-1410) is granted by the USDA. | |
| |Agency Code |Claiming Month and Year |
| | | |
| |I. GENERAL INFORMATION | |
|Name of Agency |Telephone Area/No. |
| | |
|Agency Mailing Address Street, City, State, Zip |Email Address of Preparer |
| | |
|Name of Preparer |Telephone of Preparer if different from above. |
| | |
| |II. PARTICIPATION DATA | |
| |Submit Monthly | |
| | | |
| |SMP | |
|Sites/Schools | | |
|Days Operating | | |
|Cost per ½ Pint | |This is the average dairy cost, not what your agency charges per ½ pint. |
|Free Milk | | |
|Paid Milk | | |
| |III. CERTIFICATION | |
|I HEREBY CERTIFY to the best of my knowledge that this claim is true, correct, and in accordance with the terms of existing agreements, that records are |
|available to support this claim, and that payment has not been received. Meal counts have been reviewed and analyzed to ensure accuracy. I acknowledge that |
|failure to submit accurate claims will result in recovery of an overclaim and may result in the withholding of payments, suspension, or termination of the |
|program. |
|Signature of Authorized Representative |Date Signed Mo./Day/Yr. |
|( | |
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