HomeMy WebLinkAboutResolution - 2006-R0217 - Contract Agreement For Food Services- Texas Health And Human Services Commission - 05_11_2006Resolution No. 2006-RO217
May 11, 2006
Item No. 5.21
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK
THAT the Mayor of the City of Lubbock Be and is hereby authorized and
directed to sign for and on behalf of the City of Lubbock, a Contract by and between the
City of Lubbock and Texas Health and Human Services Commission, for the 2006
Summer Food Service Program for children, and all related documents. Said Contract is
attached hereto and incorporated in this resolution as if fully set forth herein and shall be
included in the minutes of the City Council.
Passed by the City Council this 1Ith day of May , 2006.
MAYOR
ATTEST:
j�
Rebecca Garza, City Secretary
APPROVED AS TO CONTENT:
Randy Trues 1, Community Services Director
APPROVED AS TO FORM:
M.
gs/ccdocs/Summer Lunch.06
4/ 12/06
Resolution No. 2006-RO217
11, 2UU6
No. 5.21
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
SPECIAL NUTRITION PROGRAMS
AGREEMENT
STATE OF TEXAS§
COUNTY OF TRAVIS §
The Texas Health and Human Services Commission, hereinafter referred to as HHSC,
AND
CITY OF LUBBOCK
hereinafter referred to as the Contractor, do hereby make and enter into this contract, as required by the National School Lunch Act
and the Child Nutrition Act, as amended, and the following program regulations: the National School Lunch Program (NSLP), 7
Code of Federal Regulations (CFR) Part 210; the Special Milk Program (SMP), 7 CFR Part 215; the School Breakfast Program
(SBP), 7 CFR Part 220; the Summer Food Service Program (SFSP), 7 CFR Part 225; and the Child and Adult Care Food Program
(CACFP) 7 CFR Part 226.
This agreement establishes or continues the rights and responsibilities of HHSC and the Contractor pursuant to the Contractor's
participation in one or more of the above named programs as stipulated herein. If this agreement continues as an existing
agreement, all existing terms, conditions, liabilities and obligations of the parties under the prior agreement remain in full force
and effect, except to the extent that those terms, conditions, liabilities and obligations conflict with this agreement, in which case
this agreement takes precedence.
By signing this agreement, both parties are bound by its terms and conditions from its beginning effective date, or the beginning
effective date of any prior agreement/s continued by this agreement, until terminated in accordance with this agreement.
1.
MUTUAL AGREEMENTS
The Parties mutually agree:
A. If the Contractor fails to provide services in accordance with the provisions of this contract, HHSC may, upon written notice
of default to the Contractor, immediately terminate the whole or any part of this contract, including refusal to pay claims for
reimbursement, and such termination shall not be an exclusive remedy but shall be in addition to any other rights and remedies
provided by law or under this contract.
B. If federal or state laws or other requirements are amended or judicially interpreted so that the continued fulfillment of this
contract, on the part of either party, is substantially unreasonable or impossible, or if the parties are unable to agree upon any
amendment which would therefore be needed to enable the substantial continuation of the services contemplated by this
contract then, the parties shall be discharged from any further obligations created under the terms of this contract, except for
the equitable settlement of the respective accrued interest of obligations, including audit findings, incurred up to the date of
termination.
lI.
CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT
A. The Contractor will comply with the applicable regulations for its designated program, as well as 7 CFR Parts 245 and 250, as
amended, the Uniform Federal Assistance Regulation (7 CFR, Part 3015, as amended), Audits of State, Local Governments,
and Non -Profit Organizations (7 CFR 3052, as amended) and state policies and procedures as issued and amended by HHSC.
Mav 1) r
II.
CONTRACTOR PROGRAM ADMINISTRATION AND FINANCIAL MANAGEMENT
(Continued)
The Contractor further agrees to perform as described in its application (including its Policy statement and supporting
documents, and approved amendments to the application) for participation in the designated program.
B. The Contractor accepts final administrative and financial responsibility for food service operations in each school, summer
feeding site, and child and/or adult care facility, hereinafter referred to as a site, operated or sponsored by the Contractor. The
responsibility includes any audit exceptions or payment deficiency in the program covered by this contract, and all
subcontracts hereunder, which are found after monitoring or auditing by HHSC or USDA and will be responsible for the
collections and payback of any amount paid in excess of the proper claim amount.
C. The Contractor submits for HHSC approval only those applications for sites which have delegated the authority for the
administration of food service operations to the Contractor or which have executed sub agreements with the Contractor for the
administration of food services operations.
D. Contractors participating in the NSLP agree:
1. That the official signing the Claim for Reimbursement will be responsible for reviewing and analyzing meal
counts to ensure accuracy and compliance with federal regulations
2. To enter into an agreement to receive donated foods as required by federal regulations
3. To price the lunch as a unit
4. To claim reimbursement at the assigned rates only for reimbursable free, reduced price and paid lunches served
to eligible children in accordance with 7 CFR part 210
5. Count the number of free, reduced price and paid reimbursable meals served to eligible children at the point of
service, or through another counting system if approved by HHSC
6. Limit its net cash resources to an amount that does not exceed 3 months average expenditures for its nonprofit
school food service or such other amount as may be approved in accordance with 7 CFR §210.19(a); and
7. Maintain a financial management system as prescribed under 7 CFR §210.14(c)
E. Contractors participating in the CACFP shall provide or accept responsibility for the provision of organized, non-residential
child day care and will immediately report to the Texas Department of Family and Protective Services (DFPS) Licensing or
Child Protective Services staff, any suspected violations of DFPS Licensing standards or suspected abuse of children in
sponsored centers or day homes.
F. CONTRACTOR understands that acceptance of funds under this Contract acts as acceptance of the authority of the State
Auditor's Office ("SAO"), or any successor agency, to conduct an investigation in connection with those funds.
CONTRACTOR further agrees to cooperate fully with the SAO or its successor in the conduct of the audit or investigation,
including providing all records requested. CONTRACTOR will ensure that this clause concerning the authority to audit funds
received indirectly by subcontractors through CONTRACTOR and the requirement to cooperate is included in any
subcontract it awards.
RECORD KEEPING
A. The Contractor will keep financial and supporting documents, statistical records, and any other records pertinent to the
services for which a claim was submitted in the manner and detail prescribed by HHSC. Unless otherwise provided by state or
federal law, the records and documents will be kept for a minimum of 3 years and 90 days after the termination of the federal
fiscal year for the relevant program. If any litigation, claim, or audit involving these records begins before such period expires,
the Contractor will keep the records and documents for not less than 3 years and 90 days and until all litigation, claims or
audit findings are resolved. The case is considered resolved when there is a final order issued in litigation, or a written
agreement is entered into between HHSC and the Contractor. The Contractor will keep records of non -expendable property
acquired under the contract for 3 years and 90 days after final disposition of the property.
B. The Contractor and its subcontractors will allow HHSC and USDA officials and other appropriate officials determined by
HHSC to inspect facilities and records and to audit, examine, and copy records at any reasonable time. This includes access to
all records of costs paid, even in part, by HHSC.
MflY 9 a )nne
RECORD KEEPING
(Continued)
C. The Contractor and its subcontractors will establish a method to secure the confidentiality of records and other information
relating to clients in accordance with the applicable federal law, rules, and regulations, as well as the applicable state law and
regulations. The provision shall not be construed as limiting the Department's right of access to recipient case records or other
information relating to clients served under this contract.
IV.
CIVIL RIGHTS POLICY COMPLIANCE
A. The Contractor agrees to comply with Title VI of the Civil Rights Act of 1964 (Public Law 88-352) and all requirements
imposed by the regulations of the Department of Agriculture (7 CFR Part 15), Department of Justice (28 CFR Parts 42 and 50)
and FNS directives or regulations issued pursuant to that act and the regulations. Section 504 of the Rehabilitation Act of 1973
(public Law 93-112), the Americans with Disabilities Act of 1990 (public Law 101-336), Title IX of the Education
Amendments of 1972 (7 CFR Part 15a), the Age Discrimination Act of 1975 (Public Law 94-135), and all amendments to
each, and all requirements imposed by the regulations issued pursuant to these acts. In addition the contractor agrees to
comply with Title 40, Chapter 73, of the Texas Administrative Code. These provide in part that no person in the United States
shall, on the ground of race, color, national origin, sex, age, disability, political beliefs, or religion be excluded from
participation in, or denied any aid, care, service or other benefits provided by federal and/or state funding, or otherwise be
subjected to discrimination. The contractor also agrees to comply with Health and Safety Code Section 85.113 (relating to
workplace and confidentiality guidelines regarding AIDS and HIV).
Additionally, Title VI of the Civil Rights Act of 1964, and its implementing regulations at 45 CFR, Part 80 or 7 CFR, Part 15,
prohibit a contractor from adopting and implementing policies and procedures that exclude or have the effect of excluding or
limiting the participation of clients in its programs, benefits, or activities, on the basis of national origin. Also, 40 TAC, Part
1, §73.206 requires contractors to provide alternative methods for ensuring access to services for applicants and recipients
who cannot express themselves fluently in English. Accordingly, the contractor agrees to ensure that its policies do not have
the effect of excluding or limiting the participation of persons in its programs and activities, on the basis of national origin.
The contractor also agrees to take reasonable steps to provide services and information, both orally and in writing, in
appropriate languages other than English, in order to ensure that persons with limited English proficiency are effectively
informed and can effectively participate in and benefit from its programs. The Contractor accepts final administrative
responsibility for ensuring that its subcontractors take reasonable steps to provide services and information, both orally and in
writing, in appropriate languages other than English, in order to ensure that persons with limited English proficiency are
effectively informed and can effectively participate in and benefit from that subcontractor's programs and services.
The contractor hereby gives assurance that it will immediately take any measures necessary to comply with this subsection..
B. This assurance is given in consideration of and for the purpose of obtaining any and all federal financial assistance, grants and
loans of federal funds, reimbursable expenditures, grant or donation of federal property and interest in property, the detail of
federal personnel, the sale and lease of, and the permission to use, federal property or interest in such property or the
furnishing of services without consideration or at a nominal consideration, or at a consideration which is reduced for the
purpose of assisting the recipient, or in recognition of the public interest to be served by such sale, lease or furnishing of
services to the recipient, or any improvements made with federal financial assistance extended to the program applicant by the
HHSC. This includes any federal agreement, arrangement, or other contract that has as one of its purposes the provision of
cash assistance for the purchase of food, and cash assistance for purchase or rental of food service equipment or any other
financial assistance extended in reliance on the representation and agreements made in this assurance.
C. The Contractor agrees to compile data, maintain records, and submit reports as required, to permit effective enforcement of
the above Acts and permit authorized HHSC, USDA and FNS personnel during normal working hours to review such records,
books, and accounts as needed to ascertain compliance with the above Acts. If there are any violations of this assurance,
HHSC, USDA and FNS have the right to seek judicial enforcement of this assurance. This assurance is binding on the
Contractor, its successors, transferees, and assignees as long as it receives assistance or retains possession of any assistance
from the department. The person whose signature appears on this contract is authorized to sign this assurance on the behalf of
the Contractor.
MAY 2 6 2008
IV.
CIVIL RIGHTS POLICY COMPLIANCE
(Continued)
D. A religious or charitable organization is eligible to be a contractor on the same basis as any other private organization. The
contractor retains its independence from State and local governments, including the contractor's control over the definition,
development, practice, and expression of its charitable or religious beliefs. Except as provided by federal law, HHSC shall not
interpret this contract to require a charitable or religious organization to alter its form of internal governance or remove
religious art, icons, scripture, or other symbols. Furthermore, if a religious or charitable organization segregates the
govenunent funds provided under the contract, then only the financial assistance provided by these funds will be subject to
audit. However, neither HHSC's selection of a charitable or faith -based contractor of services nor the expenditure of funds
under this contract is an endorsement of the contractor's charitable or religious character, practices, or expression. The purpose
of this contract is the provision of services; no State expenditures have as their objective the funding of sectarian worship,
instructions, or proselytization.
A charitable or faith -based provider of services under this contract shall reasonably apprise all assisted individuals of the
following: "Neither HHSC s selection of a charitable or faith -based provider of services nor the expenditure of funds under
this contract is an endorsement of the provider's charitable or religious character, practices, or expression. No provider of
services may discriminate against you on the basis of religion, a religious belief, or your refusal to participate in a religious
practice. If you object to a particular provider because of its religious character, you may request assignment to a different
provider. If you believe that your rights have been violated, please discuss the complaint with your provider or notify your
local HHSC Special Nutrition Programs office.
Section 104 of The Personal Responsibility and Work Opportunity Reconciliation Act of 1996. 42 U.S.C. § 604a, sets forth
certain additional rights and responsibilities for charitable and faith -based providers of services, certain additional rights of
assisted individuals, and certain additional responsibilities of HHSC to these providers and assisted individuals. This contract
is subject to those additional rights and responsibilities.
I►m
HHSC CLAIMS PAYMENT
A. HHSC will, subject to the federal appropriation and availability to HHSC of sufficient funds for the applicable program, make
program payment to the Contractor in accordance with the terms of this agreement No reimbursement shall be made for
performance under this agreement occurring prior to (a) the beginning effective date of this agreement or (b) a later date
established by HHSC based on the date of receipt of a fully executed copy of this agreement
B. This paragraph is pursuant to §2252.903 of the Government Code. Any payments owing to the contractor under this contract
will be applied toward elimination of the contractor's indebtedness to the state, delinquency in payment of taxes to the state, or
delinquency in payment of taxes that the comptroller administers or collects until the indebtedness or delinquency is paid in
full.
VI.
IMMIGRATION
The Contractor- agrees to comply with the requirements of the Immigration Reform and Control Act of 1986 regarding employment
verification and retention of verification forms for any individuals hired after November 6, 1986, who will perform any labor or
services under this contract.
VII.
CERTIFICATION
A. Regarding Debarment, Suspension, Ineligibility, or Voluntary Exclusion For Covered Contracts - The contractor certifies, by
execution of this agreement, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from participating in this contract by any federal department or agency or by the State of
Texas. By making this certification the contractor agrees to the following terms:
MAY 2 R mr.
VII.
CERTIFICATION
(Continued)
The above certification is a material representation of fact upon which reliance was based when this contract was
entered into. if it is later determined that the contractor knowingly rendered an erroneous certification, in addition to
other remedies available to the federal government, the Department of Health and Human Services, United States
Department of Agriculture or other federal department of agency, or the Texas Health and Human Services
Commission may pursue available remedies, including suspension and/or debarment. The contractor shall provide
immediate written notice to the person to which this certification is submitted if at any time the contractor learns that
the certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
2. The words 'covered contract," "debarred," suspended," "ineligible," "participant," "person," "principal," "proposal,"
and voluntarily excluded," as used in this certification have meanings based upon materials in the Definitions and
overage sections of federal rules implementing Executive Order 12549. Usage is defined in the attachment.
3. The contractor agrees by submitting this certification that, should the proposed covered contract be entered into, it
shall not knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or
voluntarily excluded from participation in this covered transaction, unless authorized by the Department of Health
and Human Services, United States Department of Agriculture or other federal department or agency, and/or the
Texas Health and Human Services Commission, as applicable.
5. The contractor further agrees by submitting this certification that it will include HHSC Form titled "Certification
Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts" without
modification, in all covered subcontracts and in all solicitation for all covered subcontracts.
6. A contractor may rely upon a certification of a subcontractor that it is not debarred, suspended, ineligible, or
voluntarily excluded from the covered contract, unless it knows that the certification is erroneous. A contractor must,
at a minimum, obtain certificates from its covered subcontractor upon each subcontractor's initiation and upon each
renewal.
Nothing contained in all the foregoing shall be construed to require establishment of a system of records in order to render
in good faith the certification required by this certification document. The knowledge and information of a contractor is
not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.
7. Except for contracts authorized under paragraph 4 of these terms, if a contractor in a covered contract knowingly
enters into a covered subcontract with a person who is suspended, debarred, ineligible, or voluntarily excluded from
participation in this transaction, in addition to other remedies available to the federal government, Department - of
Health and Human Services, United States Department of Agriculture, or other federal department or agency, as
applicable, and/or the Texas Health and Human Services Commission may pursue available remedies, including
suspension and/or debarment.
B. Regarding Federal Lobbying - This certification applies only to this contract and is a material representation of fact upon
which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for
making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required
certification shall be subject to a civil penalty of not less than $10,000 and not more than S100,000 for each such failure.
The contractor certifies, to the best of his or her knowledge and belief, that:
No federally appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for
influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of
Congress, or an employee of a member of Congress in connection with the awarding of any federal contract, the making of
any federal grant, the making of any federal loan, the entering into of any cooperative agreement, or the extension,
continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement.
If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting
to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an
employee of a member of Congress in connection with this federally funded contract, subcontract, sub grant, or cooperative
agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in
accordance with its instructions.
as A», A - w__.
VII.
CERTIFICATION
(Continued)
The contractor shall require that the language of this certification be included in the award documents for all covered sub
awards at all tiers (including subcontracts, sub grants, and contracts under grants, loans, and cooperative agreements) and that
all covered sub recipients shall certify and disclose accordingly.
C. Regarding Conflicts of Interest — The contractor agrees to comply with applicable state and federal laws, rules and regulations
regarding conflicts of interest in the performance of its duties under this Agreement. Contractor warrants that it has no interest
and will not acquire any direct or indirect interest that would conflict in any manner or degree with its performance under this
Agreement.
Contractor will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents
the appearance of personal or organizational conflict of interest, or personal gain. Contractor will operate with complete
independence and objectivity without actual, potential or apparent conflict of interest with respect to the activities conducted
under this Agreement with the State of Texas.
An organizational conflict of interest is a set of facts or circumstances, a relationship, or other situation under which a
contractor, or a subcontractor has past, present, or currently planned personal or financial activities or interests that either
directly or indirectly:
1. Impairs or diminishes the offeror's, contractor's, or subcontractor's ability to render impartial or objective assistance or
advice to HHSC; or
2. Provides the contractor or subcontractor an unfair competitive advantage in future HHSC procurements.
Except as otherwise disclosed and approved by HHSC prior to the Effective Date of the Agreement, Contractor warrants that,
as of the Effective Date and to the best of its knowledge and belief, there are no relevant facts or circumstances that could give
rise to organizational conflict of interest affecting this Agreement. Contractor affirms that it has neither given, nor intends to
give, at any time hereafter, any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or
service to a public servant or any employee or representative of same, at any time during the procurement process or in
connection with the procurement process except as allowed under relevant state and federal law.
Contractor agrees that, if after the Effective Date, Contractor discovers or is made aware of an organizational conflict of
interest, Contractor will immediately and fully disclose such interest in writing to the HHSC Special Nutrition Programs. In
addition, Contractor must promptly disclose any relationship that might be perceived or represented as a conflict after its
discovery by Contractor or by HHSC as a potential conflict. HHSC reserves the right to make a final determination regarding
the existence of conflicts of interest, and Contractor agrees to abide by HHSC's decision.
The disclosure will include a description of the action(s) that Contractor has taken or proposes to take to avoid or mitigate
such conflicts.
If HHSC determines that an organizational conflict of interest exists, HHSC may, at its discretion, terminate the contract. If
HHSC determines that Contractor was aware of an organizational conflict of interest before the award of this Agreement and
did not disclose the conflict to the contracting officer, such nondisclosure will be considered a material breach of the
Agreement. Furthermore, such breach may be submitted to the Office of the Attorney General, Texas Ethics Commission, or
appropriate State or Federal law enforcement officials for further action.
Contractor must include the provisions of this Section C in all subcontracts for work to he performed similar to the service
provided by Contractor and the terms "Agreement," with the terms "Contractor" and "HHSC" modified appropriately to
preserve the State's rights.
Contractor has not retained or promised to retain any person or company, or utilized or promised to utilize a consultant that
participated in HHSC's development of specific criteria of the Agreement or who participated in the approval of the
Contractor for this Agreement.
Contractor will not recruit or employ any HHSC professional or technical personnel who have worked on projects relating to
the subject matter of this Agreement, or who have had any influence on decisions affecting the subject matter of this
Agreement, for two (2) years following the completion of this Agreement.
VII.
CERTIFICATION
(Continued)
Contractor certifies to its understanding and agreement regarding Conflicts of Interest.
The contractor certifies that if it is a corporation, it is either a for -profit corporation that is not delinquent in its franchise tax
payments to the State of Texas, or is a non-profit corporation or is otherwise not subject to payment of franchise taxes to the
State of Texas.
D. The contractor certifies that all information submitted pursuant to this agreement is true and correct. The contractor
understands that the deliberate misrepresentation or withholding of information is a violation of this contract and may result in
prosecution under applicable state and federal statutes.
E. Under Section 231.006, Family Code, the vendor or applicant certifies that the individual or business entity named in this
contract, bid, or application, and any individual who is a partner, shareholder, or owner with at least 25% interest in the
business entity, is not ineligible to receive the specified grant, loan, or payment and acknowledges that this contract may be
terminated and payment may be withheld if this certification is inaccurate.
VIII.
TERM AND TERMINATION
In addition to other provisions of this article allowing termination, this Agreement will terminate upon the Expiration Date unless
extended in accordance with the terms of this Agreement, or terminated sooner under the terms of this Agreement. Prior to
completion of the Initial Term and any extensions or renewal thereof, all or a part of this Agreement may be terminated for any of
the following reasons:
(a) Termination by mutual agreement of the Parties.
This Agreement may be terminated by mutual agreement of the Parties. Such agreement must be in writing.
(b) Termination in the best interest of the State.
HHSC may terminate the Agreement at any time when, in its sole discretion, HHSC determines that termination is in the best
interests of the State of Texas. The termination will be effective on the date specified in HHSC's notice of termination.
(c) Termination for cause.
HHSC reserves the right to terminate this Agreement, in whole or in part, upon the following conditions:
(1) Assignment for the benefit of creditors, appointment of receiver, or inability to pay debts.
HHSC may terminate this Agreement if CONTRACTOR:
(A) Makes an assignment for the benefit of its creditors;
(B) Admits in writing its inability to pay its debts generally as they become due; or
(C) Consents to the appointment of a receiver, trustee, or liquidator of CONTRACTOR or of all or any part of its
property.
(2) Failure to adhere to laws, rules, ordinances, or orders.
HHSC may terminate this Agreement if a court of competent jurisdiction finds CONTRACTOR failed to adhere to any
laws, ordinances, rules, regulations or orders of any public authority having jurisdiction and such violation prevents or
substantially impairs performance of CONTRACTOR's duties under this Agreement.
(3) Breach of confidentiality.
HHSC may terminate this Agreement if CONTRACTOR breaches confidentiality laws with respect to the Services and
Deliverables provided under this Agreement.
(4) Failure to maintain adequate personnel or resources.
HHSC may terminate this Agreement if, after providing notice and an opportunity to correct, HHSC determines that
CONTRACTOR has failed to supply personnel or resources and such failure results in CONTRACTOR's inability to fulfill its
duties under this Agreement.
MAY 2 6 20OR
VIII.
TERM AND TERMINATION
(Continued)
(5) Termination for gifts and gratuities.
(A) HHSC may terminate this Agreement following the determination by a competent judicial or quasi-judicial
authority and CONTRACTOR's exhaustion of all legal remedies that CONTRACTOR, its employees,
agents or representatives have either offered or given any thing of value an officer or employee of HHSC or
the State of Texas in violation of state law.
(B) CONTRACTOR must include a similar provision in each of its subcontracts and shall enforce this provision
against a subcontractor who has offered or given any thing of value to any of the persons or entities described in this
Section, whether or not the offer or gift was in CONTRACTOR's behalf.
(C) Termination of a subcontract by CONTRACTOR pursuant to this provision will not be a cause for termination of
the Agreement unless:
(1) CONTRACTOR fails to replace such terminated subcontractor within a reasonable time; and
(2) Such failure constitutes Cause as described in this Section.
(D) For purposes of this Section, a "thing of value" means any item of tangible or intangible property that has a
monetary value of more than $50.00 and includes, but is not limited to, cash, food, lodging, entertainment, and charitable
contributions. The term does not include contributions to holders of public office or candidates for public office that are
paid and reported in accordance with State and/or Federal law.
(6) Termination for non -appropriation of funds.
Notwithstanding any other provision of this Agreement, if funds for the continued fulfillment of this Agreement by
HHSC are at any time not forthcoming or are insufficient, through failure of any entity to appropriate funds or otherwise,
then HHSC will have the right to terminate this Agreement at no additional cost and with no penalty whatsoever by
giving prior written notice documenting the lack of funding.
(7) Judgment and execution.)
(A) HHSC may terminate the Agreement if judgment for the payment of money in excess of $500,000.00 that is not
covered by insurance, is rendered by any court or governmental body against CONTRACTOR, and CONTRACTOR does
not:
(1) Discharge the judgment or provide for its discharge in accordance with the terms of the judgment;
(2) Procure a stay of execution of the judgment within 30 days from the date of entry thereof; or
(3) Perfect an appeal of such judgment and cause the execution of such judgment to be stayed during the appeal,
providing such financial reserves as may be required under generally accepted accounting principles.
(B) If a writ or warrant of attachment or any similar process is issued by any court against all or any material portion of
the property of CONTRACTOR, and such writ or warrant of attachment or any similar process is not released or bonded
within 30 days after its entry, HHSC may terminate the Agreement in accordance with this Section.
(8) Termination for insolvency.
(A) HHSC may terminate the Agreement if CONTRACTOR:
(1) Files for bankruptcy;
(2) Becomes or is declared insolvent, or is the subject of any proceedings related to
its liquidation, insolvency, or the appointment of a receiver or similar officer for it;
(3) Makes an assignment for the benefit of all or substantially all of its creditors; or
(4) Enters into an Agreement for the composition, extension, or readjustment of substantially all of its obligations.
(B) CONTRACTOR agrees to pay for all reasonable expenses of HHSC including the cost of counsel, incident to:
(1) The enforcement of payment of all obligations of the CONTRACTOR by any action or participation in, or in
connection with a case or proceeding under Chapters 7, 11, or 13 of the United States Bankruptcy Code, or any successor
statute;
all nv 0 11 7nt1C
VIII.
TERM AND TERMINATION
(Continued)
(2) A case or proceeding involving a receiver or other similar officer duly appointed to handle the CONTRACTOR's
business; or
(3) A case or proceeding in a State court initiated by HHSC when previous collection attempts have been unsuccessful.
(9) Termination for CONTRACTOR'S material breach of the Agreement.
HHSC will have the right to terminate the Agreement in whole or in part if HHSC determines, at its sole discretion, that
CONTRACTOR has materially breached the Agreement.
IX.
EFFECTIVE DATE AND SIGNATURES
The parties hereto in their capacities stated, affix their signatures and bind themselves for the faithful performance of the terms of
this contract pursuant to participation in the following program or programs:
National School Lunch Program
School Breakfast Program
Special Milk Program
City of Lubbock
Name of Contracting Organization
(Please print or type)
Marc McDougal
Name of Official Signing
(Please print or type)
of Community Services
Child and Adult Care Food Program
X Summer F9dService Program
Signe of ' chaan of the board of directors
or other official ho has been authorized to sign
contracts on be alf of the contracting organization.
Mayor
Title of Official
(Please print or type)
Attest:
Q�-� — —
Rebek,ca Garza, City Secretary
Approved as to
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Effective from: 5 ' 2-00 until terminated.
By: Date:
HHSC RepreIr
yentaWe
Approved for Form by OGC: Signature on file
Revised July 2005
c4
Texas Health and Human Summer Food Service Program Forth 141506
Services Commission Application for Participation January 2006
Give as much Information as possible. Attach
additional sheets if needed; Identify each
attachment with the name of the contracting
organization.
Section I — Sponsor Information
i=or Hittlrnl�
q Nr 8_
a �
..
1
Sponsoring Organization Name
Texas ID No.
11756000590-6000
Telephone No.
1806-775-2685
Hotline No.
City of Lubbock
1806-775-2673
Mailing Address (Street or P.O. Box, City, State, ZIP)
PO Box 2000, Lubbock TX 79457
Street Address (if different)
E-mail Address
1010 91h Street Lubbock TX 79401
nneill@mall.ci.lubbock.tx.us
Name of Administrator
Title
Nancy Neill
Indoor Recreation Supervisor
Name of SFSP Contact Person
Telephone No. of Contact Person (include Area Code)
Nancy Neill
806-775-2685
A. Sponsor Classification (Check all that apply):
❑ National Youth Sports Program ❑ Residential/Nonresidential Summer Camp
® Unit of Government — Contractor certifies that all food service sites are operated directly by the contractor.
❑ School Food Authority ❑ Continuous Calendar School Year ❑ Private Nonprofit
B. Is your program a year-round program?.................................................................................................................. ❑ Yes ® No
C. Type of Sponsor:
® Public Entity
Is your agency considered to be ownedloperated?........................................................................................... ❑ Yes ® No
Do you deposit your program reimbursement directly into the State Treasury? ................................❑ NIA ❑ Yes ® No
Do you deposit your program reimbursement into a local bank?........................................................❑ NIA ® Yes ❑ No
If "Yes," is it direct deposit?....................................................................................................................... ❑ Yes ® No
❑ Private Nonprofit Organization —Tax-exempt status established. Attach letter of determination (IRS 501(c)(3)) of tax-
exempt status from IRS.
Do you deposit your program reimbursement into a local bank?........................................................❑ NIA ❑ Yes ❑ No
If "Yes," is it direct deposit?........................................................................................................................ ❑ Yes ❑ No
D. Does the organization provide an ongoing year-round service to the community that is to be served by
the Summer Food Service Program(SFSP)?........................................................................................................... ® Yes ❑ No
If "No," which of the following circumstances applies?
❑ Residential Camp ❑ Failure to operate would deny program to a poor area
❑ Serves Migrant Children ❑ Failure to operate would deny a significant number of children access to program
E. Does the organization expend $500,000 or more in federal funds yearly?............................................................... ® Yes ❑ No
Attach a copy of the audit covering last year's program operation or documentation that an audit conforming with SFSP policy will
be conducted, including the date it will be conducted.
MAY 2 6 2008
Section II — Budget
A. Estimate all SFSP costs that will be claimed for reimbursement for the program year.
Program Labor
Fringe Benefits
Food
$47,257.60
Non-food Supplies
Utilities
Rent
Equipment Use Fee
Rental of Equipment
Transportation — Rate per mile:
Others : Coolers
$500.00
Others c"
Other s
Total 1
$47 757.60
Form N1506
Page 2/01-2006
g- � �' mata� pi�tra�e►��
��y� ��.
Administrative Labor m mt., monitor; clerical
$5 220.10
Fringe Benefits
$759.98
Rental of Office Space
Utilities
Office Supplies
$100.00
Office Building Maintenance
Equipment Use Fee
Audit Fees
LegalFees
Transportation — Rate per mile:.445*4000
$1 780.00
Other s ec' : Advertising
$500.00
Other (specify):
Total
$8,360.08
B. Indicate projected income to the food service from all sources other than SFSP reimbursement. Identify exactly the costs this
income will cover. (Do not include state or federal funds.)
Source of income
Amount
Will be used for.
N/A
$
Source of Income
Amount
Will be used for:
N/A
$
Section III — Management Plan
A. List administrative -level personnel who will be responsible for management and monitoring of the SFSP. (Do not include site
supervisors, cooks, ianitors or other personnel involved in on -site food service.)
r94
Indoor Recreation Supervisor
1
Director of SFSP
Program Manager
1
Assist Program Director and Monitor
Administrative Assistant
1
Manage Records
Monitor
1
Manage Records and Personnel
MAY 2 6 2006
Form H1506
Page 3/01-2006
B. Are children charged separately for meals?.............................................................................................................. 0 Yes ® No
If "Yes; complete Form H1506, Attachment A (page 2) and submit with this application.
C. Do you want to receive advance payments:
foroperational costs?......................................................................................................................................... 0 Yes ® No
foradministrative costs?.................................................................................................................................... ❑ Yes ® No
D. If meal service is self -preparation, do you want to receive commodities?................................................................. 0 Yes 0 No
If "Yes," Form H1608, Application and Agreement for Receipt of USDA -Donated Commodities, must be completed and returned
with your SFSP application.
Section IV — Program Operation
A.1. Beginning and Ending Dates of Meal Service A.2. Number of Sites
From: May 30, 2006 To: August 4, 2006 8
B. List dates and topics of SFSP training.
E- - ki d
s �.:r
2 .f` ,a A - F; G A s1�Y ! 4 i ;v at r Y `w s
01 or i.'' S:`�.... as . �..w."��',s-,F; , ai �Ca' r,�.,-3'`""'� 'R"' -;:iE' 1 yE^,
May 26 2006
Summer Satellite Staff Training
June 1, 2006
SFSP Training LISD Monitors
C. Is the organization currently contracting with a year-round food service management company? ........................... 0 Yes ® No
If "Yes," submit a copy of your procurement procedures, bid, contract and all amendments; skip Item D. If "No," complete Item D.
D. Is the organization planning to contract with a food service management company? ............................................... ® Yes ❑ No
If "Yes," and the contract will exceed $10,000, attach a copy of the invitation to bid. Alsoprovide:
Date of Bid Publication
Place of Publication
Date of Bid Opening
73:00
Time of Bid Opening
April 2 & 9, 2006
1 Lubbock Avalanche Journal
Aril 18 2006
pm
Is bid expected to be $100,000 or more?
If "Yes," give place of bid opening.
❑ Yes 0 No
Also, attach a copy of a minimum 11-day cycle menu, including all specific menus to be used.
E. Attach a copy of the letter that has been (or will be) sent by the organization to the local health department notifying it of intent to
operate a Food Service Program at the site(s) indicated on the attached Form H1507, Site Information.
F. Are you implementing the option to allow off -site consumption of food?......................0 All Sites ❑ Some Sites ® No Sites
Section V — Assurances
A. Free Meal Policy Statement
1. The sponsoring organization assures the Texas Health and Human Services Commission (HHSC) that all children at the sites
described on the site(s) information sheets (Form H1507) for the Summer Food Service Program will be offered the same
meals with no physical segregation of, or other discrimination against, any child because of race, color, national origin, sex,
age or disability. No separate charge will be made for any meal except in accordance with Attachment A of this application.
2. The sponsoring organization assures HHSC that, if it is sponsoring camps or other enrollment programs:
• the sponsoring organization has or will obtain family size and income data about all children whose meals will be reported
as free or reduced -price; and
• the children claimed as free or reduced -price meet the current family size and income standards set by the United States
Department of Agriculture, HHSC Form H4504, Income Standards for Determining Free and Reduced -Price Eligibility.
3. If the sponsoring organization is sponsoring a camp or other enrollment program that charges separately for meals, the
sponsoring organization has read Attachment A to this application, "Additional Assurances for Camps and Other Enrollment
Programs that Charge Separately for Meals," and assures HHSC that all requirements have been or will be met.
MAY 2 6 Z006
Form H1506
Page 4/01-2006
B. Public Release
1. The sponsoring organization will make efforts to ensure that the local news media will make a public announcement of the
program and will supply them with a news release.
If the sponsoring organization is sponsoring a camp or other enrollment program, this release must contain, at a minimum, a
list of all approved sites, a list of the current standards for determining free and reduced -price eligibility, and the following
statement:
2
"The announces the sponsorship of the Summer Food Service Program.
(name of the organization)
Income eligibility will be based on family size and Income using the Standards for Determining Free and Reduced -
Price Eligibility, provided by the United States Department of Agriculture (USDA). Meals will be provided at the site(s)
listed. In accordance with federal law and USDA policy, this institution Is prohibited from discriminating on the basis
of race, color, national origin, sex, age or disability.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights,1400 Independence Avenue, SW,
Washington, D.C. 20250-9410 or call (800) 795.3272 or (202) 720-6382 (TTY). USDA Is an equal opportunity provider
and employer."
For all other groups, the announcement must contain, at a minimum, a list of all approved sites and the following statement:
"The _ announces the sponsorship of the Summer Food Service Program.
(name of the organization)
Meals will be provided at the site(s) listed. In accordance with federal law and USDA policy, this Institution is
prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW,
Washington, D.C. 20250-9410 or call (800) 795-3272 or (202) 720-6382 (TTY). USDA Is an equal opportunity provider
and employer."
This public release was or will be published in the following news media outlet(s):
Lubbock AJ Parks Guide
May 14 2006
Lubbock AJ
May 28, 2006
3. Attach a copy of the sponsoring organization's public release statement as submitted to the news media and any other
materials used to publicize the program's availability and nondiscrimination requirements.
Section VI - Waiver Requests (Check all for which you are applying; submit appropriate waiver request form and documentation.)
❑ Waiver to operate more than 25 sites (nonprofit organizations only)
❑ Waiver of the time restrictions for meal service at migrant sites
❑ Waiver of the 15-consecutive school day requirement for year-round school program sites
❑ Waiver of the first -week site visit requirement (school food authorities only)
Section VII - Certification (see Form H1506, Attachment B)
I certify that the information on this application Is true and correct to the best of my knowledge. I certify that reimbursement
will be claimed only for approved meals served to eligible children during the hours they are in attendance at approved sites. i
know that deliberate misrepresentation or withholding of information may result In prosecution under applicable state and
federal statutes.
ignature - OtnGa ponsoring Organization Date
Name (please type or print) Title
Nancy Neill I indoor Recreation Supervisor
Use
2006 Summer Lunch Menu
City of Lubbock
Day 1
Poor Boy
Day 7
Turkey & Swiss Sandwich
loz - bologna
loz - Turkey
loz - cheese
loz - Swiss cheese
1/2 oz — Salami
2 slices bread
1 sandwich bun
'/4 cup lettuce/tomato/pickle
'/4 cup lettuce/tomato/pickle
1 whole - orange
1 whole apple
1 cookie
1 cookie
8 oz. Chocolate milk
8 oz. Chocolate milk
Day 2
Peanut Butter/Jelly Sandwich
Day 8
Poor Boy
1 oz - Peanut Butter / Jelly
1 oz - bologna
2 slices - Bread
1 oz - cheese
loz - American cheese
1/2 oz — Salami
1/4 cup celery sticks
1 sandwich bun
1 whole orange
'/4 cup lettuce/tomato/pickle
8 oz. Chocolate milk
1 whole apple
1 cookie
Day 3
Turkey Ham & Cheese Sandwich
8 oz. Chocolate milk
1 oz - Turkey Ham
1 oz - American Cheese
Day 9
Peanut Butter/Jelly Sandwich
2 slices -Bread
loz - Peanut Butter / Jelly
1 whole apple
2 slices - Bread
'/4 cup carrot sticks
1oz - American cheese
2 cookies
`/4 cup - celery Sticks
8 oz. Chocolate milk
1 whole apple
8 oz. Chocolate milk
Day 4
Pastrami & Swiss Sandwich
loz - Turkey Pastrami
Day 10
Turkey Ham & Cheese Sandwich
loz - Swiss Cheese
loz - Turkey Ham
2 slices - Bread
1 oz - American Cheese
t/4 cup lettuce/tomato/pickle
2 slices -Bread
1 whole orange
1 whole orange
1 cookie
'/4 cup carrot sticks
8 oz. Chocolate milk
2 cookies
8 oz. Chocolate milk
Day 5
Ham & Cheese Sandwich
1 oz -Ham
Day 11
Pastrami & Swiss Sandwich
loz - American Cheese
loz - Turkey Pastrami
2 slices - Bread
loz - Swiss Cheese
cup lettuce/tomato/pickle
2 slices -Bread
1 whole apple
'/4 cup lettuce/tomato/pickle
2 cookies
1 whole orange
8 oz. Chocolate milk
1 cookie
8 oz. Chocolate milk
Day 6
Bologna & Cheese Sandwich
loz - Bologna
1 oz - Cheese
2 slices - Bread
`/4 cup lettuce/tomato/pickle
1 whole fruit
1 brownie
8 oz. Chocolate milk
IAAy 2 6 2�106
DATE April 3, 2006
TO Bridget Faulkenberry, Environmental Specialist
FROM Nancy Neill, Indoor Recreation Supervisor
SUBJECT Summer Lunch Program
The City Of Lubbock will once again be participating in the Summer Lunch Program for
children. This program will begin on Tuesday, May 30 and will end on Friday, August 4,
2006. Meals will be served at the following locations:
Rawlings Community Center — Harwell Gym 11:30 a.m. — 12:30 p.m.
Trejo Supercenter — 3200 Amherst 12:00 —1:00 p.m.
Simmons Community Center — 23`d and Oak 12:00 —1:00 p.m.
George Woods Center — Erskine and Zenith 12:10 —1:10 p.m.
Phea Branch of the Boys and Girls Club —1801 E. 24`h 12:15 —1:15 p.m.
In addition to these sites, LISD will be participating in the program from June 1 through
June 23. Meals will be served at 11:30 a.m. and last until 12:30 p.m. at the following
locations:
Bean Elementary — 3001 Avenue N
Ramirez Elementary — 702 Avenue T
Harwell Elementary — 40`h and Avenue B
MAY 2 6 2�6
♦ Y r o
o r
FOR IMMEDIATE RELEASE
CITY OF LUBBOCK
PARKS AND RECREATION DEPARTMENT
*** MEDIA ADVISORY ***
Summer Lunch Program Available for Youth
The City Of Lubbock is pleased to announce the Summer Food Program for Children, sponsored
by the Texas Health and Human Services Commission. This program is provided through the
City Of Lubbock Parks and Recreation Department, under direction of Civic Services. The
Program will provide a nourishing noon meal to youngsters age one through eighteen. This
program will begin on Tuesday, May 30 and will end on Friday, August 4, 2006. Meals will be
served at the following locations:
Rawlings Community Center — Harwell Gym 11:30 a.m. —12:30 p.m.
Trejo Supercenter — 3200 Amherst 12:00 —1:00 p.m.
Simmons Community Center — 23a and Oak 12:00 —1:00 p.m.
George Woods Center — Erskine and Zenith 12:10 — 1:10 p.m.
Phea Branch of the Boys and Girls Club —1801 E. 24' 12:15 — 1:15 p.m.
In addition to these sites, LISD will be participating in the program from June 1 through June 23.
Meals will be served at 11:30 a.m. and last until 12:30 p.m. at the following locations:
Bean Elementary — 3001 Avenue N
Ramirez Elementary — 702 Avenue T
Harwell Elementary — 401h and Avenue B
In accordance with federal law and USDA policy, this institution is prohibited from
discriminating on the basis of race, color, national origin, sex, age or disability.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400
Independence Avenue, SW, Washington, D.C. 20250-9410 or call (800) 795-3272 or (202) 720-
6382 (TTY). USDA is an equal opportunity provider and employer."
end/end/end
For further information, contact Nancy Neill, 775-2685.
MAY 2 6 2006
Texas Health and Human Form H1506, Attachment B
Services Commission June 2005
Summer Food Service Program for Children
Criminal Provisions and Penalties
1. Whoever, in connection with any application, procurement, record keeping entry, claim for reimbursement, or other
document or statement made in connection with the program, knowingly and willfully falsifies, conceals or covers up by
any trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or whoever in
connection with the program knowingly makes an opportunity for any person to defraud the United States or does or
omits to do any act with intent to enable any person to defraud the United States, shall be fined not more than $10,000 or
imprisoned not more than five years.
2. Whoever being a partner, officer, director, or managing agent connected in any capacity with any partnership,
association, cooperation, business, or organization, either public or private, embezzles, misapplies, steals, or obtains by
fraud, false statement or forgery, any benefit provided by the program, or any money, funds, assets, or property derived
from benefits provided by this program, shall be fined not more than $10,000 or imprisoned for not more than five years or
both. If the benefits, money, funds, assets, or property Involved is not over $200, then the penalty shall be a fine of not
more than $1,000 or imprisonment for not more than one year, or both.
3. If two or more persons conspire or collude to accomplish any act made unlawful under this subsection, and one or more
such person commit any act to effect the object of conspiracy or collusion, each shall be fined not more than $10,000 or
imprisoned for not more than five years, or both.
TERMINATION PROCEDURES
The following is a list of deficiencies that are grounds for termination. Grounds for termination, however, are not limited to
this list.
1. Non-compliance with applicable bid procedures and contract requirements of Federal Child Nutrition regulations.
2. The submission of false information to the Texas Health and Human Services Commission.
3. Program violations at a significant proportion of the sponsor's sites. Such violations include, but are not limited to the
following:
A. Non-compliance with the meal service time restrictions.
B. Failure to maintain accurate records.
C. Failures to adjust meal orders to conform to the variations in the number of participating children.
D. The simultaneous service of more than one meal to any child.
E. Service of a significant number of meals which do not include required quantities of all meal components.
F. The claiming of program payments for meals not served to participating children.
G. Excessive instances of off -site meal consumption.
H. Continued use of food service management companies that are in violation of health codes.
MAY 2 6 Z006
ATTACHMENT
SUMMER FOOD SERVICE PROGRAM (SFSP) APPLICATION
OUTREACH PLAN FOR OPEN AND RESTRICTED OPEN SITES
If you operate open sites or restricted open sites, indicate your plans for conducting outreach to
inform persons about the operation of the SFSP at your sites and promote participation at your
sites. Check all that apply.
❑ Make television announcements
❑ Send letters to potential participants.
❑ Make radio announcements.
❑ Distribute flyers to potential participants.
El Display posters at locations visited by potential participants.
54 Offer activities other than meals at sites.
❑ Partner with other organizations to advertise and promote the program.
9 Other. Explain.
Send out Press Releases to the local newspapers and radio/television stations.
Information in the Parks and Recreation Summer Activity Guide distributed
through the Lubbock Avalanche Journal. Post informationon the Parks and
Recreation website.
January 2002
MAY 2 6 2006
- s
Texas Health and Human Form H1507
Services Commission Summer Food Service Program January2006
Site Information
Name of Food Service Site Telephone No.
Maggie Tre'o Su ercenter 1806-767-2702 1 TX .� /D� ❑ R
Address of Site (Street, City, State, ZIP)
3200 Amhers, Lubbock, TX 79415t
Period of Operation of Food Service (moddaytyr.-mo.daytyr.) No. of Operating Days May June I July Aug. Sept
From: May 30, 2006 through: August 4, 2006 1 2 22 20 4 0
Attach a Map with the Site Service Area Identified
1. Indicate type of site:
❑ Residential Camp (serving one to three meals) ❑ Site Serving Primarily Migrant Children (serving one to
three meals)
❑ Nonresidential Camp (serving one to three meals) ® Other Site (serving one or two meals)
2. List ALL counties served by this site: Lubbock
3. A. Is your site an open or restricted open site?.......................................................................................................0 Yes ❑ No
B. Is your site enrolled?........................................................................................................................................... ❑ Yea ® No
C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced -price meals for the
site (SFSP Handbook, Section 2000)................................................................................................... 92.7 %
D. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For
open/restricted open sites using school data, list the schools used to document site eligibility; attach formula used by school
district to establish percentage of free and reduced -price children.
McWhorter
E. For enrolled sites, Forms H1531 will be used to document eligibility. (National Youth Sports Program — refer to SFSP
Handbook, Item 2324.)
F. What is the percentage of free and reduced -price meals for the site? ..................
4. Did the site participate in the SFSP at any time during the last five years (SFSP Handbook, Section 2000)? .......... ® Yes ❑ No
If "Yes; list the year(s) of participation and give the name of the sponsoring organization.
City of Lubbock
5. Monitoring Plan (SFSP Handbook, Section 4000) — Enter date of monitoring review to be conducted within:
A. First Week of Operation
B. First Four Weeks of Operation
1
C. Additional Reviews
1
May 30-June 2 2006
May 30-June 27, 2006
May 30-Au ust 4 2006 - - -
6. Meal Service Period Information (SFSP Handbook, Section 2000)
dr'.
,fi
Breakfast
A. M. Supplement
Lunch
140
12:00
1:00
P. M. Supplement
,Supper
'This information Is considered by HHSC when setting the approved meal service level. (SFSP Handbook, Section 2000)
7. Do you plan to feed children under one (1) year old?................................................................................................❑ Yes ® No
E)
Wethod of Food Preparation by Sponsoring Organization SFSP Handbook, Section 2000
Self -Preparation Vended
❑ On -Site ❑ Using School Food Authority ❑ Using Private Nonprofit Organization that is Self -Prep
❑ Central Kitchen ® Using Food Service Management Company excludes all -year contracts with on -site re
Jh m % 6 n5t
1. 6..
Form HIS07
Page 2/01-2006
9. A. indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP
Handbook, Section 2000)
❑ Cafeteria -style Meal Service ❑ Children are Seated and are Given Meals ® Children Line Up and Pick Up Meals
❑ Other:
B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be
implementing offer vs. serve?.............................................................................................................................❑ Yes ❑ No
10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2000)
Center Supervisor
1
Monitor daily
operations, site supervisor
Center Assistant
1
Meal Service
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2000)
® Indoor Meal Service ❑ Meal Service Will Be Cancelled
❑ Other:
12. Is this site implementing the option to allow off -site consumption of food?................................................................ ❑ Yes ® No
13. Are meals delivered to the site?.................................................................................................................................0 Yes ❑ No
If "Yes," complete Items 14, 15 and 16. If "No," form is complete except for certification at bottom.
14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections
2000 and 6000)
Z Site Personnel Will Contact Administrative Staff, Who Will Contact Vendor
❑ Site Personnel Will Communicate Directly With Vendor
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2000)..................................0 Yes ❑ No
If "No," describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of
service.
16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2000):
❑ Stored in Refrigerator and Served the Next Day ® Thrown Away at the Site ❑ Returned to Vendor for Disposal
❑ Other:
I certify that the information on this form is true and correct to the best of my knowledge. I certify that this site has been
visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know
that deliberate misrepresentation or withholding of Information may result in prosecution under applicable state and federal
statutes.
Name of Sponsoring Organization
(2 City of Lubbock
Signature - Official of Wonsoring Organization Date
Name of Official (please type or print) Title
Nancy Neill I Indoor Recreation Supervisor
%A nv
Z--
Texas Health and Human Form HIS07
Services Commission Summer Food Service Program January 2006
Site Information
Name of Food Service Site Telephone No.
Copper RaWin s mmunity Center/Harwell Gym 806-767-2704 ITX a_ ❑ R U
Address of Site (Street, City, State, ZIP)
213 40'" Street, Lubbock, TX 79404
Period of Operation of Food Service (mo./day/yr.-mo.day/yr.) No. of Operating Days May June July I Aug. Sept
From: May 30, 2006 through: Au ust 4, 2006 2 22 20 4 0
Attach a Map with the Site Service Area Identified
1, indicate type of site:
❑ Residential Camp (serving one to three meals)
❑ Site Serving Primarily Migrant Children (serving one to
three meals)
❑ Nonresidential. Camp (serving one to three meals) ® Other Site (serving one or two meals)
2. List ALL counties served by this site: Lubbock
3. A. Is your site an open or restricted open site?...................................................................................................... ® Yes ❑ No
B. Is your site enrolled?..........................................................................................................................................❑ Yes ® No
C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced -price meals for the
site (SFSP Handbook, Section 2000).................................................................................................. 86.7 %
D. if open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For
open/restricted open sites using school data, list the schools used to document site eligibility; attach formula used by school
district to establish percentage of free and reduced -price children.
Harwell
E. For enrolled sites, Forms H1531 will be used to document eligibility. (National Youth Sports Program —refer to SFSP
Handbook, Item 2324.)
F. What is the percentage of free and reduced -price meals for the site? .................................................. %
4. Did the site participate in the SFSP at any time during the last five years (SFSP Handbook, Section 2000)? .......... ® Yes ❑ No
If "Yes," list the year(s) of participation and give the name of the sponsoring organization.
City of Lubbock
5. Monitorin Plan SFSP Handbook, Section 4000 — Enter date of monitoring review to be conducted within:
A. First Week of Operation
B. First Four Weeks of Operation
C. Additional Reviews
1
May 30-June 2 2006
May 30-June 27 2006
May 30-Au ust 4 2006
6. Meal Service Period Information (SFSP Handbook, Section 2000)
'�"pqu�{ �"�a�:s%��f�����fl/
�iy�. .l� ,e�
�r
'5 ����� - %� 's� � ✓ ^{ ,37. *�✓s'.. ��� wo
�" :� .W�" � � 3
l ^4ty✓.�"�,Mq�`. >f'�
x im`# �y _ 'n":i 5 8 f � ...y y
Breakfast
A. M. Supplement
Lunch
135
11:30
12:30
P. M. Supplement
,Supper
'This Information Is considered by tf!-15(: wnen semng the approvea mea► service level. (SFSP Hanvvook, Section 2000)
7. Do you plan to feed children under one (1) year old?................................................................................................ ❑ Yes ®No
8.
Method of Food Preparation by Sponsoring Organization SFSP Handbook, Section 2000
Self -Preparation Vended
❑ On -Site ❑ Using School Food Authority ❑ Using Private Nonprofit Organization that is Self -Prep
❑ Central Kitchen ® Using Food Service Management Coma excludes all -year contracts with on -site re
�a'Ra/ ?. c= .. j, n n'r,
Form H1507
Page 2/01-2006
9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP
Handbook, Section 2000)
❑ Cafeteria -style Meal Service ❑ Children are Seated and are Given Meals ® Children Line Up and Pick Up Meals
❑ other.
B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be
implementing offer vs. serve?............................................................................................................................. [:]Yes ❑ No
10. List site Dersonnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2000)
. 777 #r3fi
rsi 1 irksiBoel��si�
_
Fir .,`
Center Supervisor
1
Monitor daily operations, site supervisor
Center Assistant
1
Meal Service
i
I
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2000)
® Indoor Meal Service ❑ Meal Service Will Be Cancelled
❑ Other:
12. Is this site implementing the option to allow off -site consumption of food?................................................................ ❑ Yes ® No
13. Are meals delivered to the site?.................................................................................................................................® Yes ❑ No
If "Yes," complete Items 14,15 and 16. If "No," form is complete except for certification at bottom.
14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections
2000 and 6000)
® Site Personnel WIII Contact Administrative Staff, Who Will Contact Vendor
❑ Site Personnel WIII Communicate Directly With Vendor
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2000)..................................® Yes ❑ No
If "No," describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of
service.
16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2000):
❑ Stored in Refrigerator and Served the Next Day ® Thrown Away at the Site ❑ Returned to Vendor for Disposal
❑ Other:
1 certify that the Information on this form Is true and correct to the best of my knowledge. I certify that this site has been
visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know
that deliberate misrepresentation or withholding of Information may result In prosecution under applicable state and federal
statutes.
Name of Sponsoring Organization
'G L- 1 (2 O( _ City of Lubbock
Signature - Offic1 Sponsoring Organization date
Name of Official (please type or print) Title
Nancy Neill I Indoor Recreation Supervisor
N
Texas Health and Human Form H1507
Services Commission Summer Food Service Program January 2006
Site Information
Name of Food Service Site Telephone No.
Mae Simmons Community Center 1806-767-2700 1 TX� ❑ R u
Address of Site (Street, City, State, ZIP)
2004 Oak Avenue Lubbock TX 79414
Period of Operation of Food Service (mo./day/yr.-mo.daylyr.) No. of Operating Days May June July I Aug. Sept.
From: May 30, 2006 through: August 4 2006 1 1 2 22 20 4 0
Attach a Map with the Site Service Area Identified
1. Indicate type of site:
❑ Residential Camp (serving one to three meals)
❑ Site Serving Primarily Migrant Children (serving one to
three meals)
❑ Nonresidential Camp (serving one to three meals) ® Other Site (serving one or two meals)
2. List ALL counties served by this site: Lubbock
3. A. Is your site an open or restricted open site?.......................................................................................................® Yes ❑ No
B. Is your site enrolled?...........................................................................................................................................❑ Yes ® No
C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced -price meals for the
site (SFSP Handbook, Section 2000)................................................................................................... 95.0 %
D. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For
open/restricted open sites using school data, list the schools used to document site eligibility; attach formula used by school
district to establish percentage of free and reduced -price children.
Iles
E. For enrolled sites, Forms H1531 will be used to document eligibility. (National Youth Sports Program — refer to SFSP
Handbook, Item 2324.)
F. What is the percentage of free and reduced -price meals for the site? .................................................. %
4. Did the site participate in the SFSP at any time during the last five years (SFSP Handbook, Section 2000)? ..........0 Yes ❑ No
If "Yes," list the year(s) of participation and give the name of the sponsoring organization.
City of Lubbock
5. Monitorino Plan (SFSP Handbook, Section 4000) — Enter date of monitoring review to be conducted within:
A. First Week of Operation
B. First Four Weeks of Operation
iMay3O-June27,2006
C. Additional Reviews
May 30-June 2, 2006 1
May 30-Au ust 4, 2006
6. Meal Service Period Information SFSP Handbook, Section 2000
.P,>
5
9 ; ir5°'ir3' gge�
K W 4P a
i
�A
f d° `7�x `q t
s '°'�Yrta` ,.��
' '�
!fqy yy^ Y
»'Ff y alp R f8$ 's BY. Y TS
&a�
,teem"
an
Breakfast
A. M. Supplement
Lunch
130
12:00
1:00
P. M. Supplement
Supper
`This information is considered by HHSC when setting the approved meal service level. (SFSP Handbook, Section 2000)
7. Do you plan to feed children under one (1) year old?................................................................................................ ❑ Yes ® No
8.
Aethod of Food Preparation by Sponsoring Organization SFSP Handbook, Section 2000
Seff-Preparation Vended
❑ On -Site ❑ Using School Food Authority ❑ Using Private Nonprofit Organization that is Self -Prep
❑ Central Kitchen ® Using Food Service Management Company excludes all -year contracts with on -site re
MAY 2 6 206
Form H1507
Page 2/01-2006
9. A. indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP
Handbook, Section 2000)
❑ Cafeteria -style Meal Service ❑ Children are Seated and are Given Meals ® Children Line Up and Pick Up Meals
❑ Other.
B. if using cafeteria -style meal service and if sponsor is a school food authority, will the site be
implementingoffer vs. serve?.............................................................................................................................❑ Yes ❑ No
10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2000)
WS,
Center Supervisor
1
Monitor daily operations, site supervisor
Center Assistant
1
Meal Service
Camp Monitor
1
Monitor and Daily Operations
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2000)
® Indoor Meal Service ❑ Meal Service Will Be Cancelled
❑ Other:
12. Is this site implementing the option to allow off -site consumption of food?................................................................❑ Yes ® No
13. Are meals delivered to the site?.................................................................................................................................0 Yes []No
If "Yes," complete Items 14,15 and 16. If "No," form is complete except for certification at bottom.
14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections
2000 and 6000)
® Site Personnel Will Contact Administrative Staff, Who Will Contact Vendor
❑ Site Personnel Will Communicate Directly With Vendor
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2000)..................................® Yes ❑ No
If "No," describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of
service.
16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2000):
❑ Stored in Refrigerator and Served the Next Day ® Thrown Away at the Site ❑ Returned to Vendor for Disposal
❑ Other:
I certify that the information on this form Is true and correct to the best of my knowledge. i certify that this site has been
visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know
that deliberate misrepresentation or withholding of Information may result in prosecution under applicable state and federal
statutes.
Name of Sponsoring Organization
U �VZJWCity of Lubbock
Signature - Oiflcial ponsoring Organization Date
Name of Official (please type or print) Title
Nancy Neill I Indoor Recreation Supervisor
Texas Health and Human
Services Commission
Name of Food Service Site
Summer Food Service Program
Site Information
Telephone No.
PHEA Boys and Girls Club 806-763-0204 1 TX I R kU
Address of Site (Street, City, State, ZIP)
1801 E. 24 h Street Lubbock TX 79404
Period of Operation of Food Service (mo./daytyr.-mo.day/yr.) No. of Operating Days May June July Aug. Sept
From: May 30 2006 through: August 4, 2006 2 22 20 4 0
Form HIS07
January 2006
Attach a Map with the Site Service Area Identified
Q 1. Indicate type of site:
❑ Residential Camp (serving one to three meals)
❑ Site Serving Primarily Migrant Children (serving one to
three meals)
❑ Nonresidential Camp (serving one to three meals) ® Other Site (serving one or two meals)
2. List ALL counties served by this site: Lubbock
3. A. is your site an open or restricted open site?.......................................................................................................® Yes ❑ No
B. Is your site enrolled?...........................................................................................................................................❑ Yes ® No
C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced -price meals for the
site (SFSP Handbook, Section 2000)................................................................................................... 94.3 %.
D. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For
open/restricted open sites using school data, list the schools used to document site eligibility; attach formula used by school
district to establish percentage of free and reduced -price children.
Dupre Elementary
E. For enrolled sites, Forms H1531 will be used to document eligibility. (National Youth Sports Program —refer to SFSP
Handbook, Item 2324.)
F. What is the percentage of free and reduced -price meals for the site? ............ ............. I........................ %
4. Did the site participate in the SFSP at any time during the last five years (SFSP Handbook, Section 2000)? ..........® Yes ❑ No
If "Yes," list the year(s) of participation and give the name of the sponsoring organization.
City of Lubbock
5. Monitorinci Plan (SFSP Handbook, Section 4000) — Enter date of monitoring review to be conducted within:
A. First Week of Operation
B. First Four Weeks of Operation
C. Additional Reviews
May 30-June 2, 2006
1 May 30-June 27 2006
May 30-Au ust 4 2006
6. Meal Service Period Information (SFSP Handbook, Section 2000)
IN
�777
0i" 2¢J
M4I
'
2,
N,
x K61. ,..i?lv !`
�1..rsA" Zy
R.�.,m
-"' {
;.#.d,
Breakfast
A. M. Supplement
Lunch
100
12:15
1:15
P. M. Supplement
,Supper
'This information is considered by HHSC when setting the approved meal service level. (SFSP Handbook, Section 2000)
7. Do you plan to feed children under one (1) year old?................................................................................................ ❑ Yes ® No
M
dethod of Food Preparation by Sponsoring Organization SFSP Handbook, Section 2000
Self -Preparation Vended
❑ On -Site ❑ Using School Food Authority ❑ Using Private Nonprofit Organization that is Self -Prep
Central Kitchen I ® Using Food Service Management Company (excludes all -year contracts with on -site prep)
Form HIS0T
Page 2/01-2006
9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP
Handbook, Section 2000)
❑ Cafeteria -style Meal Service ❑ Children are Seated and are Given Meals ® Children Line Up and Pick Up Meals
❑ Other:
B. If using cafeteria -style meat service and if sponsor Is a school food authority, will the site be
implementingoffer vs. serve?.............................................................................................................................❑ Yes ❑ No
10. Ust site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2000)
9 ,f
i�
G` eR .� � k .: ^ <°�
.`i
.a. _ '�s�iR"?x» °;'Y bc. w'+ 'y..,c a A�, ^f. .'� �
Scm t�oioi jj �y`a
Ain,
pe
^tc`4�'x4.. L -, `£e ?�?y /+�� - � �"i .4^f•.�:.
Site Supervisor
1
Monitor daily operations, daily meal service
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2000)
® Indoor Meal Service ❑ Meal Service Will Be Cancelled
❑ Other:
12. Is this site implementing the option to allow off -site consumption of food?................................................................❑ Yes ® No
13. Are meals delivered to the site?.................................................................................................................................23 Yea ❑ No
If "Yes," complete Items 14,15 and 16. If "No," form is complete except for certification at bottom.
14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections
2000 and 6000)
® Site Personnel WIII Contact Administrative Staff, Who WIII Contact Vendor
❑ Site Personnel Will Communicate Directly With Vendor
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2000)..................................® Yes ❑ No
If "No," describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of
service.
16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2000):
❑ Stored in Refrigerator and Served the Next Day ® Thrown Away at the Site ❑ Returned to Vendor for Disposal
❑ Other.
I certify that the information on this form Is true and correct to the best of my knowledge. I certify that this site has been
visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know
that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal
statutes.
Name of Sponsoring Organization
`21 b to City of Lubbock
Signature — OffirJo Sponsoring Organization Date
Name of Official (please type or print) Title
Nancy Neill I Indoor Recreation Supervisor
Texas Health and Human Form H1507
Services Commission Summer Food Service Program January 2006
Site Information
Name of Food Service Site Telephone No.
Harwell Elements 1806-766-1711 TX ❑ R U
Address of Site (Street, City, State, ZIP)
4101 Avenue D,Lubbock TX 79404
Period of Operation of Food Service (moddaylyr.-mo.day/yr.) No. of Operating Days May June July Aug. Sept.
From: June 1, 2006 through: June 23 2006 0 17 0 0 0
Attach a Map with the Site Service Area Identified
1. Indicate type of site:
❑ Residential Camp (serving one to three meals)
❑ Site Serving Primarily Migrant Children (serving one to
three meals)
❑ Nonresidential Camp (serving one to three meals) ® Other Site (serving one or two meats)
2. List ALL counties served by this site: Lubbock
3. A. Is your site an open or restricted open site?.......................................................................................................® Yes ❑ No
B. is your site enrolled?...........................................................................................................................................❑ Yes ® No
C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced -price meals for the
site (SFSP Handbook, Section 2000)................................................................................................... 86.7 %
D. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For
open/restricted open sites using school data, list the schools used to document site eligibility; attach formula used by school
district to establish percentage of free and reduced -price children.
Harwell Elementary
E. For enrolled sites, Forms H1531 will be used to document eligibility. (National Youth Sports Program —refer to SFSP
Handbook, Item 2324.)
F. What is the percentage of free and reduced -price meals for the site? ..................................................
4. Did the site participate in the SFSP at any time during the last five years (SFSP Handbook, Section 2000)? ..........0 Yes
If "Yes," list the year(s) of participation and give the name of the sponsoring organization.
City of Lubbock
5. Monitoring Plan (SFSP Handbook, Section 4000) — Enter date of monitoring review to be conducted within:
❑ No
A. First Week of Operation
B. First Four Weeks of Operation
iJunel-23,2006
C. Additional Reviews
iJunel-23,2006
June 1-2 2006
6. Meal Service Period Information (SFSP Handbook, Section 2000)
7.
8.
$t%^
X^R". 4
,�.^.' ;. �
� � e ➢�
ef��E'.�e
Breakfast
A. M. Supplement
Lunch
135
11:30
12:30
P. M. Supplement
,Supper
'This information is considered by HMSC when setting the approved meal service level. (SFSP Handbook, Section 2000)
Do you plan to feed children under one (1) year old? ...................................................... .......................................... ❑ Yes ® No
Aethod of Food Preparation by Sponsoring Organization SFSP Handbook, Section 2000
Self -Preparation Vended
❑ On -Site ❑ Using School Food Authority ❑ Using Private Nonprofit Organization that is Self -Prep
❑ Central Kitchen ® Using Food Service Management Company excludes all -year contracts with on -site re
MAY 2 6 Z006
Form H1507
Page 2/01-2006
9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP
Handbook, Section 2000)
❑ Cafeteria -style Meal Service ❑ Children are Seated and are Given Meals ® Children Line Up and Pick Up Meals
❑ Other.
B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be
implementing offer vs. serve?.............................................................................................................................❑ Yes ❑ No
10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2000)
"ks� .� .Z^ki'C^cT
%'. �£ _
;i`?F ..'.:;.F.3. a-�".F. �.3 f°� n��
",.,.hh' fi�f, i'�d�A .t.. '.A •' ti' n '..� Tca. , �..R.
^ .gk.'�h'n..
Site Supervisor
1
Monitor daily operations, daily meal service
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2000)
® Indoor Meal Service ❑ Meal Service Will Be Cancelled
❑ Other:
12. Is this site implementing the option to allow off -site consumption of food?................................................................❑ Yes ® No
13. Are meals delivered to the site?.................................................................................................................................® Yes ❑ No
If "Yes," complete Items 14,15 and 16. If "No," form is complete except for certification at bottom.
14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections
2000 and 6000)
® Site Personnel Will Contact Administrative Staff, Who Will Contact Vendor
❑ Site Personnel Will Communicate Directly With Vendor
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2000)..................................® Yes [:]No
If "No," describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of
service.
16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2000):
❑ Stored in Refrigerator and Served the Next Day ® Thrown Away at the Site ❑ Returned to Vendor for Disposal
❑ Other:
I certify that the information on this form Is true and correct to the best of my knowledge. I certify that this site has been
visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. I know
that deliberate misrepresentation or withholding of information may result In prosecution under applicable state and federal
statutes.
Name of Sponsoring Organization
City of Lubbock
Signature — Official coponsoring Organization D to
Name of Official (please type or print) Title
Nancy Neill I Indoor Recreation Supervisor
Texas Health and Human
Services Commission
Summer Food Service Program
Site information
Form HIS07
January 2006
Name of Food Service Site Telephone No,
Bean Elementary 806-766-1666 TX ❑ R
Address of Site (Street, City, State, ZIP)
3001 Avenue N Lubbock, TX 79405
Period of Operation of Food Service (mo./day/yr.-mo.day/yr.) No. of Operating Days May I June July I Aug. Sept.
From: June 1, 2006 through: June 23, 2006 0 17 0 0 0
Attach a Map with the Site Service Area Identified
1. Indicate type of site:
❑ Residential Camp (serving one to three meats)
❑ Site Serving Primarily Migrant Children (serving one to
three meals)
❑ Nonresidential Camp (serving one to three meals) ® Other Site (serving one or two meals)
2. List ALL counties served by this site: Lubbock
3. A. Is your site an open or restricted open site?.......................................................................................................0 Yes ❑ No
B. Is your site enrolled?...........................................................................................................................................❑ Yes ® No
C. Site Eligibility: Enter the percentage of children eligible for free andior reduced -price meals for the
site (SFSP Handbook, Section 2000)................................................................................................... 96.8 %
D. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For
open/restricted open sites using school data, list the schools used to document site eligibility; attach formula used by school
district to establish percentage of free and reduced -price children.
Bean Elementary
E. For enrolled sites, Forms H1531 will be used to document eligibility. (National Youth Sports Program —refer to SFSP
Handbook, Item 2324.)
F. What is the percentage of free and reduced -price meals for the site? .................................................. %
4. Did the site participate in the SFSP at any time during the last five years (SFSP Handbook, Section 2000)? ..........23 Yes ❑ No
If "Yes," list the year(s) of participation and give the name of the sponsoring organization.
City of Lubbock
5. Monitoring Plan SFSP Handbook, Section 4000 — Enter date of monitoring review to be conducted within:
A. First Week of Operation
B. First Four Weeks of Operation
iJunel-23,2006
C. Additional Reviews
I
June 1-2, 2006
June 1-23, 2006
6. Meal Service Period Information (SFSP Handbook, Section 2000)
7
8
5 } d3 'FsG4'St2�
�4 �
FP^s <:t,.2.w
?s.,. w.,,1
Breakfast
A. M. Supplement
Lunch
80
11:30
12:30
P. M. Supplement
Supper
`This information is considered by HHSC when setting the approved meal service level. (SFSP Handbook, Section 2000)
Do you plan to feed children under one (1) year old?................................................................................................❑ Yes ® No
Aethod of Food Preparation by Sponsoring Organization SFSP Handbook, Section 2000
Self -Preparation Vended
❑ On -Site ❑ Using School Food Authority ❑ Using Private Nonprofit Organization that is Self -Prep
❑ Central Kitchen ® Using Food Service Management Company excludes all - year contracts with on -site re
MAY 2 6 2006
Form H1507
Page 2/01-2006
9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP
Handbook, Section 2000)
❑ Cafeteria -style Meal Service ❑ Children are Seated and are Given Meals ® Children Line Up and Pick Up Meals
❑ Other.
B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be
implementing offer vs. serve?.............................................................................................................................❑ Yes ❑ No
10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2000)
`�
yy
..
;3 SR'.i`w
Site Supervisor
1
Monitor daily
operations, daily meal service
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2000)
® Indoor Meal Service ❑ Meal Service Will Be Cancelled
❑ Other: —
12. Is this site implementing the option to allow off -site consumption of food?................................................................❑ Yes ® No
13. Are meals delivered to the site?.................................................................................................................................® Yes ❑ No
If "Yes," complete Items 14, 15 and 16. If "No," form Is complete except for certification at bottom.
14, Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections
2000 and 6000)
® Site Personnel Will Contact Administrative Staff, Who Will Contact Vendor
❑ Site Personnel Will Communicate Directly With Vendor
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2000).................................. ® Yes ❑ No
If "No," describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of
service.
16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2000):
❑ Stored In Refrigerator and Served the Next Day ® Thrown Away at the Site ❑ Returned to Vendor for Disposal
❑ Other
I certify that the information on this form is true and correct to the best of my knowledge. I certify that this site has been
visited and that It has the capability and facilities for the meal service planned for the number of children anticipated.) know
that deliberate misrepresentation or withholding of Information may result In prosecution under applicable state and federal
statutes.
Name of Sponsoring Organization
12 City of Lubbock
Signature — Official of Sp6Aoring Organization Date
Name of Official (please type or print) Title
Nancy Neill Indoor Recreation Supervisor
Texas Health and Human Form H1507
Services Commission Summer Food Service Program January 2006
Site Information
Name of Food Service Site Telephone No.
Ramirez Elementary 1806-766-1833 TX ❑ R U
Address of Site (Street, City, State, ZIP)
702 Avenue T, Lubbock, TX 79401
Period of Operation of Food Service (moddaytyr.-mo.daytyr.) No. of Operating Days May June July I Aug. Sept.
From: June 1 2006 through: June 23 2006 0 17 0 0 0
Attach a Map with the Site Service Area Identified
1. Indicate type of site:
❑ Residential Camp (serving one to three meals)
❑ Site Serving Primarily Migrant Children (serving one to
three meals)
❑ Nonresidential Camp (serving one to three meals) ® Other Site (serving one or two meals)
2. List ALL counties served by this site: Lubbock
3. A. Is your site an open or restricted open site?.......................................................................................................® Yes ❑ No
B. Is your site enrolled?...........................................................................................................................................❑ Yes ® No
C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced -price meals for the
site (SFSP Handbook, Section 2000).................................................................................................. 79.9 %
D. If openlrestricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For
open/restricted open sites using school data, list the schools used to document site eligibility; attach formula used by school
district to establish percentage of free and reduced -price children.
Ramirez Elementary
E. For enrolled sites, Forms H1531 will be used to document eligibility. (National Youth Sports Program —refer to SFSP
Handbook, Item 2324.)
F. What is the percentage of free and reduced -price meals for the site? .................................................. %
4. Did the site participate in the SFSP at any time during the last five years (SFSP Handbook, Section 2000)? ..........® Yes ❑ No
If "Yes," list the year(s) of participation and give the name of the sponsoring organization.
City of Lubbock
5. Monitoring Plan (SFSP Handbook, Section 4000) — Enter date of monitoring review to be conducted within:
A. First Week of Operation
B. First Four Weeks of Operation
C. Additional Reviews
iJunel-23,2006
June 1-2 2006
I June 1-23, 2006
6. Meal Service Period Information (SFSP Handbook, Section 2000)
7
8
3..a.., 2Uy ✓' � ��raT,�-�S f �
R �r �t�jiif,
� �� {
We
�'"'T#� fF' �5 li�r' '• .d F
.z..y � 2+ {� F p . ,
K �� �L � �s�"sa�
. S' ., etw`0„ .. .,r N,
�M4 "{�"�` � ��
Breakfast
A. M. Supplement
Lunch
90
11:30
12:30
P. M. Supplement
,Supper
'This information is considered by HHSC when setting the approved meal service level. (SFSP Handbook, Section 2000)
Do you plan to feed children under one (1) year old?................................................................................................❑ Yes ® No
Method of Food Preparation by Sponsoring Organization SFSP Handbook, Section 2000
Self -Preparation Vended
❑ On -Site ❑ Using School Food Authority ❑ Using Private Nonprofit Organization that is Self -Prep
❑ Central Kitchen ® Using Food Service Management Company excludes all -year contracts with on -site re
MAY 2 b 200i"s
Form H7507
Page 2/01-2006
9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP
Handbook, Section 2000)
❑ Cafeteria -style Meal Service ❑ Children are Seated and are Given Meals ® Children Line Up and Pick Up Meals
❑ Other:
B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be
implementingoffer vs. serve?.............................................................................................................................❑ Yes ❑ No
10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2000)
`s»e:2m'§ R�
�,+.�Y
i»`V^ 4 .s.
°S-t h yj"�`pY`+15 ""y�"iw l� -s x.�.'x✓^ f%'
i VYt-.
.� 77A r
': .
Site Supervisor
1
Monitor daily operations, daily meal service
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2000)
® Indoor Meal Service ❑ Meal Service Will Be Cancelled
❑ Other:
12. Is this site implementing the option to allow off -site consumption of food?................................................................❑ Yes ® No
13. Are meals delivered to the site?................................................................................................................................*0 Yes ❑ No
If "Yes," complete Items 14, 15 and IS. If "No," form Is complete except for certification at bottom.
14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections
2000 and 6000)
® Site Personnel Will Contact Administrative Staff, Who Will Contact Vendor
❑ Site Personnel Will Communicate Directly With Vendor
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2000)..................................® Yes ❑ No
If "No," describe arrangements within standards prescribed by local health authorities for delivery and holding of meals until time of
16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2000):
❑ Stored in Refrigerator and Served the Next Day ® Thrown Away at the Site ❑ Returned to Vendor for Disposal
❑ Other:
I certify that the information on this form Is true and correct to the best of my knowledge. I certify that this site has been
visited and that It has the capability and facilities for the meal service planned for the number of children anticipated. l know
that deliberate misrepresentation or withholding of Information may result In prosecution under applicable state and federal
statutes.
Name of Sponsoring Organization
City of Lubbock
Signature —'Official sodng Organization Date
Name of Official (please type or print) Tide
Nancy Neill I Indoor Recreation Supervisor
Texas Health and Human Form HIS07
Services Commission Summer Food Service Program January 2006
Site Information
Name of Food Service Site Telephone No.
Lubbock Regional Mental Health & Retardation
1806-763-1036 TX ❑ R t!
Address of Site (Street, City, State, ZIP)
515 North Zenith Lubbock TX 79403
Period of Operation of Food Service (moddaylyr.-mo.daytyr.) No, of Operating Days May June July Aug. Sept.
From: May 30 2006 through: August 4, 2006 1 2 22 20 4 0
Attach a Map with the Site Service Area identified
1. Indicate type of site:
❑ Residential Camp (serving one to three meals) ❑ Site Serving Primarily Migrant Children (serving one to
three meals)
❑ Nonresidential Camp (serving one to three meals) ® Other Site (serving one or two meals)
2. List ALL counties served by this site: Lubbock
3. A. Is your site an open or restricted open site?.......................................................................................................El Yes ❑ No
B. Is your site enrolled?...........................................................................................................................................❑ Yes ® No
C. Site Eligibility: Enter the percentage of children eligible for free and/or reduced -price meals for the
site (SFSP Handbook, Section 2000)................................................................................................... 93.2 %
D. If open/restricted open sites, submit documentation supporting this percentage figure (such as census data, school data). For
open/restricted open sites using school data, list the schools used to document site eligibility; attach formula used by school
district to establish percentage of free and reduced -price children.
Parkway Elementary
E. For enrolled sites, Forms H 1531 will be used to document eligibility. (National Youth Sports Program — refer to SFSP
Handbook, Item 2324.)
F. What is the percentage of free and reduced -price meals for the site? .................................................. %
4. Did the site participate in the SFSP at any time during the last five years (SFSP Handbook, Section 2000)? .......... ® Yes ❑ No
If "Yes," list the year(s) of participation and give the name of the sponsoring organization.
City of Lubbock
5. Monitorina Plan (SFSP Handbook, Section 4000) — Enter date of monitoring review to be conducted within:
A. First Week of Operation
B. First Four Weeks of Operation
C. Additional Reviews
1
May 30-June 2, 2006
1 May 30-June 27 2006
May 30-Au ust 4, 2006
6. Meal Service Period Information (SFSP Handbook, Section 2000)
7.
8.
0���F;
����
�
<g
Breakfast
A. M. Supplement
Lunch
100
12:10
1:10
P. M. Supplement
,Supper
'This information is considered by HHSC when setting the approved meal service level. (SFSP Handbook, Section 2000)
Do you plan to feed children under one (1) year old?................................................................................................❑ Yes ® No
Aethod of Food Preparation by Sponsoring Organization SFSP Handbook, Section 2000
Self -Preparation Vended
❑ On -Site ❑ Using School Food Authority ❑ Using Private Nonprofit Organization that is Self -Prep
❑ Central Kitchen ® Using Food Service Management Company excludes all -year contracts with on -site re
MAY 2 6 ZOOS
Form H1507
Page 2/01-2006
9. A. Indicate the system to be used for the serving of meals and the supervision of children during meal service period. (SFSP
Handbook, Section 2000)
❑ Cafeteria•style Meal Service ❑ Children are Seated and are Given Meals ® Children Line Up and Pick Up Meals
❑ Other.
B. If using cafeteria -style meal service and if sponsor is a school food authority, will the site be
Implementingoffer vs. serve?.............................................................................................................................❑ Yes ❑ No
10. List site personnel who will be involved to any extent in the meal service. (SFSP Handbook, Section 2000)
-¢`t'�10
Center Supervisor
1
Monitor daily operations, site supervisor
Center Assistant
1
Meal Service
11. Indicate what provisions will be made for meal service during periods of inclement weather. (SFSP Handbook, Section 2000)
® Indoor Meal Service ❑ Meal Service Will Be Cancelled
❑ Other.
12. Is this site implementing the option to allow off -site consumption of food?................................................................❑ Yes ® No
13. Are meals delivered to the site?.................................................................................................................................0 Yes ❑ No
If "Yes," complete Items 14, 15 and 16. If "No," form is complete except for certification at bottom.
14. Indicate the means of communication with the vendor which will be used to adjust meal deliveries. (SFSP Handbook, Sections
2000 and 6000)
® Site Personnel Will Contact Administrative Staff, Who Will Contact Vendor
❑ Site Personnel Will Communicate Directly With Vendor
15. Will delivery be within one hour of the food service period? (SFSP Handbook, Section 2000)..................................® Yes F No
If "No," describe arrangements within standards prescribed by local heaith authorities for delivery and holding of meals until time of
16. If there is an excess of meals delivered, meals will be (SFSP Handbook, Section 2000):
❑ Stored in Refrigerator and Served the Next Day ® Thrown Away at the Site ❑ Returned to Vendor for Disposal
❑ Other:
I certify than the information on this form is true and correct to the best of my knowledge. I certify that this site has been
visited and that it has the capability and facilities for the meal service planned for the number of children anticipated. 1 know
that deliberate misrepresentation or withholding of Information may result In prosecution under applicable state and federal
statutes.
Name of Sponsoring Organization
Q(o City of Lubbock
ature —Official -pnsoring Organization Date
Name of Official (please type or print) Tile
Nancy Neill I Indoor Recreation Supervisor
P:;7im -
2A
MAY 2 6 2006
-RWf' ' : L I SD -SIFT. FAX NO. : 6067661210 Mar. 02 2006 02: 44PM P2
ELEMENTARY ECONOMICALLY DISADVANTAGED (STUDENTS ON FREE OR REDUCED -PRICE LUNCH)
FALL PEIMS SNAPSHOT, OCT08ER 28, 2005
CAMPUS
Economically
Dlsadvanta
Ame9
94.6%
9ess
83.7%
Bean
90.8
Bowie
50.9%
Somnan
OSI719
Z
83.3%
Duom
94.3%
Guadalupe
98.0%
Hvdwick
52.1%
Harwell
86.7
Rod9=2
27.396
89.
money
13.3
Iks
la5.096
Jackson
84.2
McWhorter
92.7
Maed
67.4
Murfee
S.4%
Overton
75.79
Parkway
93.2%
Parsons
W.5
Ramirez
79.9%
Rush
51.9%
Smith
13.1 %
Stewed
73.7%
Tubbs
86-
Water
41.4%
Wester
13.8%
Whentley
93.3%
Wheelock
82.1 %
Whiteside
15.6%
Wil ems
52159
Wilson Roscoe
2 .2%
WoMferth
91.4%
Wil ht
8 .4%
MAY 2 6 20W
Texas Health and Human Special Nutrition Programs Form H1
Services Commission Single Audit Identification Data April z
For Program Year 2006
(SNP Use Only)
Part I
Contractor Name
Contact Person
City of Lubbock
Nancy Neill
Address (Street or P.O. Box, City, State, ZIP Code)
PO Box 2000, Lubbock, TX 79457
Area Code and Telephone No.
Texas ID No.
Contract No.
( 806 ) 775 — 2685
1-75-6000590-6000
75- J5001
Contractor Fiscal Year End (mm/dd/yyyy)
Type of Contract
9/30/20Qg
❑ For Profit ❑ Nonprofit ❑ State Agency ® Other
Part ii
Check the appropriate box(es) to indicate the type(s) of program(s) In which you currently participate or for which you are applying
Commodity Assistance Programs
Program Nos.
Cash Reimbursement Programs
Program Nos.
❑ A - National School Lunch
❑ AD - Adult Day Care
TX -
El B - Charitable Institutions
❑ BL- National School Lunch/Breakfast
TX -
El C - Area Agency on Aging
❑ CC - CACFP Center
TX -
❑ G - Summer Camps
❑ DH - CACFP Day Home
TX -
❑ H - Summer Food Service
® SF - Summer Food
TX - 152-1004
❑ J - Jails
❑ SM - Special Milk
TX -
❑ I - TEXCAP
❑ TE - TEXCAP
TX -
❑ CS - Commodity Supplemental Food Prog.
❑ CS - Commodity Supplemental Food Prog.
TX -
Part III
A. Does your agency expend federal funds from programs other than those listed above? ® Yes ❑ No
If yes, complete Part III, B.
B. Give the source and amount of any federal funds that your agency expended in your most recent completed fiscal year.
Source Amount
Community Development Block Grant $2,637,000
South Plains Association of Govemments-Senior Meals and Transportation Grant $194,080
Part IV
Single Audit Exemption - I certify that I am not required to submit an audit under the Single Audit Act for the following reason.
Check only one choice.
❑ I am a for -profit organization.
❑ I am a military base.
❑ I am a nonprofit organization and expend less than $500,000 annually in total federal funding.
❑ 1 am an Indian Reservation.
I understand that if I meet the requirements of the Single Audit Act, now or in the future, I must submit an audit as a condition of
eligibility to participate in the Special Nutrition Programs, and that failure to do so as required could result in adverse action, including
the withholding of my claim for reimbursement payments and termination of my contract. I also understand that if I am a private non-
profit organization subject to the requirements of the Single Audit Act and have a financial audit performed annually, I must also obtain
a single audit on an annual basis.
Date
Name please type or print) Title 6 ��ga
Nancy Neill Indoor Recreation Supervisor IM 2
Texas Health and Human Form H"
Services Commission Special Nutrition Program July 20
Certification of Authority
This is to certify that the following erson s :
Name of Authorized Representative (please type or print) Title
Nancy Neili Indoor Recreation Supervisor
X
ignature — Authorkgh Representative
Name of Authorized Representative (please type or print) 1 Title
X
Is (are) designated as an Authorized Representative of -
Name of Contracting Organization
City of Lubbock
Address (Street, City, State, ZIP)
PO Box 2000, Lubbock, TX 79457
The representatives) designated above, and myself, acknowledge that each Is individually authorized on behalf of the
contracting organization to make written agreements with the Texas Health and Human Services Commission (HHSC) to
operate a food program, to sign documents or reports about the agreement and to present claims for reimbursement, when
appropriate, to the department.
By signing this document, we certify individually and collectively that to the best or our knowledge and belief, all documents
submitted physically or electronically on behalf of the above named contracting organization pursuant to our participation in
any and all programs administered by Special Nutrition Programs, HHSC, aretwill be true and correct In all respects, that
they are/will be completed according to the terms and conditions of existing agreements, including amendments, that
records are/wlil be available to support any and all claims and that we will not submit claims (excluding amended/adjusted
claims) for goods or services for which we have already received payment. We recognize that we are fully responsible for
any excess amounts which may result from errors made in relation to the completion and submission of claims. We are also
aware that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and
federal statutes.
Name of Official of Contracting Agency (please type or print) Title
,4 11 Mayor
IMark McDoucal f �'I I Attekt: Rebecca Garza, City Secretark'_)
X
- Official of
DELETED AUTHORIZED REPRESENTATIVES A contracting organization may not have more than three (3) authorized
representatives, including the official of the cohtrqcting agency. If you are deleting an authorized representative, list the .
name(s) of the individuai(s) to be removed as authorized representatives) below:
Name of Deleted Representatfve Name of Deleted Representadve Name of Deleted Representative I
Approo co eTit
R&iby Truesdell.
Director, Community Services
For HHSC Use Only
Contract No.
75 —
Appro t
2- ?
n Knigh
Assistant City Attorney
62
Date/Rece' ed
SO t�
Resolution No. 2006-RO217
2006
5.21
State of Texas
Health & Human Services Commission
Nondisclosure Statement
Acknowledclment
As a contractor to the Texas Health & Human Services Commission, I have been provided access to
information, systems, operations, or procedures that are security sensitive or have been identified as confidential
by the Health & Human Services Commission, the State of Texas, or the United States Government. As such, I
acknowledge the following:
• that my access to this information is provided solely in my capacity as a contractor to the Texas Health &
Human Services Commission;
• that access to this information is solely for the purpose of discharging my duties or the duties of my
employer under Texas Health & Human Services Commission contract number HHSC-_-_-_;
• that premature or unauthorized disclosure of this information will irreparably hann the interests of the State
of Texas and the Texas Health & Human Services Commission and may constitute a violation of Section
39.02 of the Texas Penal Code, the antitrust laws of the United States and the State of Texas, and the
Texas Public Information Act [chapter 552, Texas Government Code];
• that the information may represent confidential or proprietary information, the release of which may
restricted or prohibited by law.
Agreement
In view of the foregoing, I agree that I shall use any information that I receive in my capacity as a contractor to
the Texas Health & Human Services Commission — whether written or oral, formal or informal — for the following
purposes only:
• to provide the services "and/or deliverables required or requested under contract number HHSC _
to provide advice, opinion or recommendation requested by the Texas Health & Human Services
Commission in the course of fulfilling the duties prescribed under the contract;
to assist the Texas Health & Human Services Commission in developing any documents, reports, working
papers, evaluations, schedules, or instruments necessary to fulfill the requirements of the contract.
I further agree that I shall regard any such information as confidential and that I shall not disclose, reveal,
communicate, impart or divulge the information or any summary or synopsis of the information in any manner or
any form whatsoever, except under the following circumstances:
• when authorized in writing by the Project Manager employed by the Texas Health & Human Services
Commission;
• when required by court order, subpoena, or ruling of the Attorney General of Texas;
• when advised by legal counsel that disclosure is required by law or legal process;
• when the information has previously been released to the general public by the Project Manager, the Texas
Health & Human Services Commission;
• when required to brief or inform a superior, provided the superior is informed of and has also executed a
non -disclosure statement.
In the event I receive a request for information relating to contract number HHSC _ either during or
after the performance of this contract, I agree to do the following:
• notify the Project Manager or the Texas Health & Human Services Commission as soon as practical
following receipt of the request;
• seek advice from appropriate legal counsel regarding my ability to disclose the information.
By signing this statement, 1 acknowledge that 1 understand and agree to adhere to the limitations
on disclosure described above.
(Z
sr re Date
Mr C
Pdntad Umm
MAY 2 6 ZA
(certificate of Training
Awarded to
CITY OF LUBBOCK PARKS AND RECREATION
represented by
NANCY M NEILL
for successful completion of the
Summer Food Service Program
Special Nutrition Programs
Texas Health & Human Services Commission
Presented Thursday, April 6, 2006
Instructor
MAY 2 6 2006
APPLICATION PACKET - NON -SCHOOL CURRENT SPONSORS
PROGRAM YEAR 2006
Below is a list of forms that must be completed and submitted to HHSC. Please complete the required number of
copies of these forms and submit them to your Area Program Office (APO) no later than April 15, 2006. Copies of
these forms are available by either downloading them from the Special Nutrition Programs web site,
www.summerfood.ora or by copying them from the Forms Section of the SFSP Handbook. Forms that are not
contained in the Forms Section of the SFSP Handbook are enclosed.
FORM
TITLE OF FORM
NUMBER
INSTRUCTIONS
TO
SUBMIT
SNP Agreement (July
Texas Health and Human Services
2
Two SNP Agreements must be completed, signed with
2005)
Commission Special Nutrition Programs
original signatures, and returned. A signed form will be
Agreement
returned to you after HHSC approves your application and
agreement.
Form H 1506
Summer Food Service Program Application
2
Two copies must be completed, signed with original
(January 2006)
for Participation
signatures, and returned. A signed form will be returned to
you after HHSC approves your application.
Form H1506 /
Summer Food Service Program for Children
2
Submit two copies if your organization will operate camps or
Attachment A
Additional Assurances for Camps and Other
other enrolled programs that charge separately for meals.
(January
( arY 2006 )
Enrollment Programs that Charge Separately
for Meals
Form
Summer Food Service Program for Children
j
Submit one copy.
H 1506/Attachment B
Criminal Provisions and Penalties
June 2005
Outreach Plan
Summer Food Service Program (SFSP)
j
Complete and submit to your APO.
Attachment
Application Outreach Plan for Open and
(January 2002)
Restricted Open Sites
Form H1507
Summer Food Service Program Site
2 per site
Submit original and one copy for each feeding site
(January 2006
Information
participating under your agreement.
Form H 1569
Special Nutrition Programs Single Audit
2
Submit an original and one copy.
(April 2005
Identification Data, for Program Year 2006
Form H 1628
Summer Food Service Program Invitation
2
For organizations who plan to contract with a Food Service
(January 2006)
For Bid and Contract
Management Company to provide SFSP meals. Submit an
original and one copy for each solicitation for bids.
Form H4508
Special Nutrition Programs Certificate of
2
Submit an original and one copy. Use this form to add,
(July 2005
Authority
change, or delete Authorized Representatives.
Nondisclosure
Nondisclosure Statement
j
Submit an original and one copy.
Statement
Charitable Choice
Special Nutrition Program Charitable Choice
Optional
Data Form
Complete and return with application.
TACAA Census Form
Summer Food Service Program TACAA
Complete this form if you want to receive census tract
2005 Census Tract Data Request Forms
information and submit it to the Texas Association of
Community Action Agencies (TACCA) as specified on the
form.
Proof of Tax Exemption (Non -Profit
If you are a Non -Profit Organization submit a copy of your
Organizations Only)
IRS Tax Exemption Letter.
Training Certificate
Training Certificate verifying completion of
]
Submit a copy of the training certificate with your completed
required TO trainin
application Keep the on inal for vour files.
It is recommended that you keep a copy of all documents submitted with your application (rev. 1/2006).
MAY 2 6 2006
ATTACHMENT #1
SPECIAL NUTRITION PROGRAM AREA PROGRAM OFFICES
❑ Austin Area Program Office
Texas Health and Human Services Commission
Special Nutrition Programs, MC 017-3
1601 Rutherford Lane, Bldg. D-1
(78754)
PO Box 15995
Austin, Texas 78761
Telephone: (512) 873-6326
Region 07
❑ Fort Worth Area Program Office
Texas Health and Human Services Commission
Special Nutrition Programs, MC 128-9
1501 Circle Drive, Suite 155
Fort Worth, Texas 76119
Telephone: (817) 321-8101
Region 03
Lubbock Area Program Office
Texas Health and Human Services Commission
Special Nutrition Programs, MC 217-5
1716 Parkway Drive
Lubbock, Texas 79403
Telephone: (806) 766-6174
Regions 01, 02
❑ Pharr Area Program Office
Texas Health and Human Services Commission
Special Nutrition Programs, MC885-1
1503 West Polk
Pharr, Texas 78577
Telephone: (9%) 702-5541
Region 11
❑ II Paso Area Program Office
Texas Health and Human Services Commission
Special Nutrition Programs, MC 111-2
7100 Gateway East, Suite 207 (79915)
PO Box 981017
El Paso, Texas 79998-1017
Telephone: (915) 774-7449
Regions 09,10
❑ Houston Area Program Office
Texas Health and Human Services Commission
Special Nutrition Programs, IviC 182-2
9460 Harwin (77036)
PO Box 16017
Houston, Texas 77222
Telephone: (713) 735-8930
Region 06
❑ Lufkin Area Program Office
Texas Health and Human Services Commission
Special Nutrition Programs, MC 220-1
1210 South Chestnut
Lufkin, Texas 75901
Telephone: (936) 637-7533
Regions 04, 05
❑ San Antonio Area Program Office
Texas Health and Human Services Commission
Special Nutrition Programs, MC 2794
11307 Roszell (78217)
PO Box 23990
San Antonio, Texas 78223-0990
Telephone: (210) 655-6986
Region 08
MAY 2 6 2006
Revised 1/2006