PI-6070-A CACFP Addendum to Application/Agreement



|[pic] |Wisconsin Department of Public Instruction |INSTRUCTIONS: Complete and return as part of the Application/Agreement (PI-1459, |

| |CHILD AND ADULT CARE FOOD PROGRAM |PI-1486) |

| |ADDENDUM TO APPLICATION/AGREEMENT |WISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION |

| |PI-6070-A (Rev. 09-19) |ATTN: AMANDA CULLEN |

| | |COMMUNITY NUTRITION TEAM |

| | |PO BOX 7841 |

| | |MADISON, WI. 53707-7841 |

| |MONITOR STAFFING REQUIREMENTS—SPONSORING ORGANIZATIONS with 25 or more Facilities | |

INSTRUCTIONS: The first Interim CACFP Rule requires that all sponsoring organizations with 25 or more facilities document and meet the requisite staffing ratios. Complete the table below, providing all the specified information. (A full time employee works a total of 2080 hours per year.) The department will analyze the data to ensure that the required monitor staffing ratio has been met. Detailed employee position descriptions that include the percentage of time devoted to each job activity/duty, including monitoring-related activities, must be submitted as part of the management plan included with the CACFP Application/Agreement. Audit documentation that substantiates all submitted information must be maintained on file. Copy, complete and submit additional pages of this form if needed.

| |MONITORING STAFF | |

|Name |Position |Hours per |Days per |Total |Minus Non CACFP Hours |Minus CACFP Non |Net Yearly Hours spent |

| | |Day |Year |Hours/Year |per Year |Monitoring Hours |on CACFP Monitoring2 |

| | | | | | |per Year1 | |

| 1.       |      |    |    |0[pic]0 |      |      |0[pic]0 |

| 2.       |      |    |    |0[pic]0 |      |      |0[pic]0 |

| 4.       |      |    |    |0[pic]0 |      |      |0[pic]0 |

| 6.       |      |    |    |0[pic]0 |      |      |0[pic]0 |

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| 10.       |      |    |

I HEREBY CERTIFY that all information submitted as part of this addendum is true and correct to the best of my knowledge. I understand that this information is being provided in connection with the receipt of federal funds and that deliberate misrepresentation may subject me to prosecution under applicable state and federal criminal statutes.

|Name of Sponsoring Organization |Agreement Number |

|      |      |

|Name of Authorized Representative Please print |Signature of Authorized Representative |Date Signed |

|      |( | |

|MONITORING STAFF (cont’d) |

|Name |Position |Hours per |Days per |Total |Minus Non CACFP Hours |Minus CACFP Non |Net Yearly Hours spent |

| | |Day |Year |Hours/Year |per Year |Monitoring Hours per |on CACFP Monitoring2 |

| | | | | | |Year1 | |

|11.       |      |   |    |0[pic]0 |      |      |0[pic]0 |

|12.       |      |   |    |0[pic]0 |      |      |0[pic]0 |

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