Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Resolution - 4842 - Application - TDHS - Summer Food Service Program - 05_25_1995
Resolution No. 4842 May 25, 1995 Item #13 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 execute for and on behalf of the City of Lubbock a Summer Food Service Program Application and related documents with the Texas Department of Human Services, attached herewith, which shall be spread upon the minutes of the Council and as spread upon the minutes of this Council shall constitute and be a part of this Resolution as if fully copied herein in detail. Passed by the City Council this ATTEST: �� a rlly- etty M. rohnson—,—Qity Secretary APPROVED AS TO CONTENT: Doug Goo m anaging Director of Health & C� unity Services APPROVED AS TO FORM: arold Willard, Assistant CityAttorney HW js/F00DPR0G.RFS ccdocs/May 15, 1995 -as Department o, rr. 4 5,.6 + man servlr»a July I9W CERTIFICATE OF AUTHORITY This Is to certify that None of Authorized OffreMl (please typo or pnnt) Title Todd Steelman Recreation Superintendent Sgnature—Authored Official Is designated as the authorized representative of NartM of Contracting Organization Citv of Lubbock Address (Street, C4y. State, ZIP) P.O. Bo_{ 2000 Lubbock Ty 79457 The representative designated above Is authorized on behalf of the contracting organization to make written agree- ments with the Texas Department of Human Services to operate a food program, to sign documents or reports about the agreement, and to present claims for reimbursement, when appropriate, to the department. Name of C a mnv 75 1Q0r Agency Date Tale FOR DEPARTMENT OF HUMAN SERVICES USE ONLY: Agreement No. Repwed By Date TX' 'e.as Depanment Human services Form 4506 July 19W I CERTIFICATE OF AUTHORITY This is to certify that i I Name of Authorized Official (piease type or print) Tale Susan Bailey- Recreation Outreach Coordinator I S, Authorized ®tf, I ii f is designated as the authorized representative of Name of Contracting Organizauoei City of Lubbock Address (Street. City. State. ZIP) P.O. Box 2000 Lubbock TX 79457 The represent a desig ed above is authorized on behalf of the contracting organization to make written agree- ments with the Texas Depart nt of Hum operate a food program, to sign documents or reports about the agreement, and to presen pfalms r reImb merit, w 77ropriate, to the department. CI � / May 25, 1995 S gnature— vial f G4ntracttng Ag c Date Name of Official tplease type or print) Title David R. Lan.-Ston MavOr FOR DEPARTMENT OF HUMAN SERVICES USE ONLY: Agreement No. Received By Date TX- I �ara Department Form 4saa I"11nan Sorr+ce■ Jury IM CERTIFICATE OF AUTHORITY This Is to certify that Vane of Aufhonzed Of ict.al (pleasa type or print) Tale Breann Baldwin Senior Bookeeper SoQnature—Authonzed Official Is designated as the authorized representative of Name of Contracting Organization City o `Lubbock Rddress (Street, Crty, State, ZIP) P.O. Sox 2000 Lubbock, TX 79557 The represe ated above Is authorized on behalf of the contracting organization to make written agree- ments wit the Texas Dep meat of Human Servic to operate a food program, to sign documents or reports about the agree ent, and to prestof claims f ur ment, when appropriate, to the department. i t Mav 25, 1995 of ContractiN AC)Oncy Date I Name of oPhc,al (please type or prnt) Ttle 11 David 'l. Lan,stun i "lavar FOR DEPARTMENT OF HUMAN SERVICES USE ONLY: AQreement rva. Reserved $y Date {, TX- -is departrnent Form 1 s%, enaf1 SONio°s SUMMER FOOL] SERVICE PROGRAM FOR DNS STAFF ONLY APPLICATION FOR PARTICIPATION TX Na.Ett. oat' 7- Approved For NOTE: Give as much Information as possible. Attach additional sheets It needed; ❑ Breakfast ❑ A.M. Supp. ❑Lunch, i please identity each attachment with the name of the contracting organization. ❑ P.M. Supp. Supper All -CTiON [—SPONSOR INFORMATION r,7actxV Orpenuabon Name vendor ID No. Teiepnone No. Hotline No. Citv of Lubbock 17560005906000 (896 ) 767-2675 i,np Address (Street or P.o. BOX, City, State, ZIP) " P.O. Box 2000 Lubbock T`{ 79457 � "t Address (if afferent) 916 TExas Avenue Lubbock TX 79401 i.-a or Administrator ride Susan BAilev Recreation Outreach Coordinator Contractor Classification (Check all that apply): Academic Year National Unit of Government -Contractor ceitfies that all food ❑ National Youth Sports Program ❑ Youth Sports Program ❑ service sites are operated directly by the contractor. ResidentiaJINonresidential Continuous Calendar ❑ School Food Authority ❑ Summer Camp ❑ School Year ❑ Private Non-profit Is your program a year-round program? ... ❑ Yes ❑ No Type of Contractor: 2 Public Entity (explain): Ci t,. Gove rnr^en t Is your agency considered to be state owned/operated? ................ ..................................................... ❑ Yes ❑ No Do you deposit your program reimbursement drectly into the Stale Treasury? .. _ ..... .......... . .... '—NIA []Yes ❑,t� o Do you deposit your program reimbursement into a local bank? ................................ . .................... ❑ N/A 'Yes ❑ No If yes, is it direct deposit? ................................... . . ............ ❑ Yes ❑ No Private Nonprofit Organization-Tax-exernrt status established. Attach letter of determination (IRS 501.30) of tax-exempt status from IRS, Do you deposit your program reimbursement into a local bank? ......................................... . ........... ❑ N/A ❑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 Elhic 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 =.1. Does the organization receive $100,000 or more in federal funds yearly? ...... . . ........... ........ []Yes ❑ No 2. Does the organization receive more than $25.000 but less than $100,000 in federal funds yearly? . ............... . .... . . []Yes � No 3. 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. For- 'dy'E Are children charged separately for meals? ............. . ............... ❑Yes l' yo .................. it yes, see Form 1508, Attachment 8. Do you want to receive advance payments? ................................... .............. . Eyes [:No If yes,1. For Operational Costs?. • ................ .......................... .............................................. ❑ Yes C NC 2. For Administrative Costs? .... ........ ❑Yes CNc N/A if meal service is self -preparation, do you want to receive commodities? ..... .................... . ... ❑ Yes F� t yes, Form 1608, Application and Agreement for Commodities, must be completed. =CTION IV -PROGRAM OPERATION June 5, 1995 Beginning and Ending Dates of Meal Service: From — through August 11, 1995 10 Numberof sites: ........................... ... __ ... ........... ............ ................................... . List dates and topics of SFSP training: DATES TOPICS �splanation of Program, Site Management, Record Keeping,heal Requirements Inventor%, Nondiscrimination i :s the organization planning to contract with a food service management company _ or the preparation of ,:nitized meats? ....... . ...................--......................... ........... ........ .. Yes _._.tv: ves, and the contract will exceed S10,000. attach a copy of the rvitaticn to bid. Also give: mate of Bid Puoijcation Place of Tt;oncawn Date of Sod Opening I Time of Bid Opening I is oci7 exceed to oe S 100.000 0r more? y !f yes, g[ve place of boo opening: E] Yes E] No 4 Also, attach a copy of an 11-day-cyde menu including all specific menus to be used. D, Is the organization contracting with a year-round food service management company? ...... ...Eyes E No It yes, submit a copy of your procurement procedures, bid, contract, and all amendments. c. Attach a copy of the letter which has been (or will be) sent by the organization to the Health Department notifying them of intent to operate a Food Service Program at the site(s) indicated on the attached Site Information sheet (Form 1507). SECTION V-ASSURANCES :�. Free Meal Policy Statement 1.The contracting organization assures the Texas Department of Human Services (OHS) that all children at the sites described on tte Site(s) Information Sheets for the Summer Food Service Program, will be offered the same meals with no physical segregation of, or ott c. discrimination against, any child because of race, color, disability, age, sex. national origin, religion, or political beliefs. No separate char;= MI be made for any meal except in accordance with attachment B of this application. 2. The contracting organization assures DHS that. if it is sponsoring camps or other enrollment programs: • The contracting organization has or will obtain family size and income data about all children whose meals will be reported as free .- reduced -price; and • The children claimed as free or reduced -price meet the current fatuity size and income standards set by the United States Departmer• _ Agriculture, DHS Form 4504, Standards for Determining Free and Reduced -Price Efigibility. aanrrKnt - _. - -" SUMMER FOOD SERVICE PROGRAM FOR CHILDREN CIVIL RIGHTS QUESTIONNAIRE . illL RIGHTS ACT OF 1954 t. Estimate, by racaUethnic group, the number of children that will participate in the program at each site. EI the program c:.r,ss'-: of several camp sessions, specify the pro4ee;ed number of children by site and date of session: 1 SSTE A.ti1EA4CkH ALASKAN I pAr-r ` I ►�Gi�I 8LACK (namr 61 els, school, amp, •tc.) f :H[StAN I N:,i1YE i :SLANDER:SLANDEREA Ht5?4N�C I 'N1t17E Burns Park ; 3 ! _' 113 I 96: 527 } Carlisle Park 17 75 t 117 790 ChaLman Park i I 6 � 3 � 500 � 300 Sf) Hollins Park 3 i 137 i , 1,176 ?`'S Pioneer Park 1 I 43 I 15? 323 891 2. neS=^'L9 hCw t`tiS r rC'eCt onwas n d 9 { a., tad cn C rT ar3;-r9 err- : - t n 5.".=$.:cS3R',;,Orl of 5. d$f 5 Census maces t`te organization have scec:r'c marrbers� p reG:irer^ar,;s wr icn res in t~a da^.at of r� prcgram gene'its to specit<c grcucs?........................................................... . ... Yes 'f Yes, �escr:-e t�csa reGulremer,ts: ?''cr-s Y.,.:l :e "a:e =y -..rCr , - _ :r:_ :�1 _a,CrS Cl..:X%7. -f :a27 _ _d ; _- nlllo _1`1C . .5.3. , _ers, Hor_' mouth D. ,v/-2iwG`ercL; 3ac:" _.Ycsw1, :3.ar3. : .'a---za.C.^..� '-z ,= c'S -e _a ti^ .i . .as'S _7 -Ca ti an ecc.a, pa ca:a ..-e _. 'Has any `ecerai acency rc(,`ea ,`e or, -a zat:en ct ncn--ccmcliance rntn ;Frs C: it R:cn;s a;; ........ . ... Yes if yes, live cetails inc,uding dates, r'arres, and .-esuls: R=NA31LiTAT1O^i ACT OF 1973 (Section 504) A. OceS ;`e =rtrac;ing 4ryanlzat:cn nave any x:ic:es, rra� ,.' S, �r 3r�. �a r'@.'S ' a; :r"it. --any, :r ?i— .1iscCurage ;amc:--aticn in the crGC,ra,'V er^cicy7'grt ;:y :tie :anzaticri :e:..3:.sa -t e;sa:+.+Cr? .. ..... '� Yes it yes, ezctain: -ar.1-lent- `"^ SUMMER FOOD SERVICE PROGRAM FOR CHILCREN i""N CIVIL RIGHTS QUESTIONNAIRE .'(L RIGHTS ACT OF 1964 '. Estimate, by raciaVethnic group, the num�-er at c't;ldren that will participate in the program at each site. ;t the program CCr.s.Su of several camp sessions, soecit• the protec- ed rt;m�:er of Chlidren 5v srte and date of session: Sr'E (nalno of 014, acnool, camp, SIC.) I AJVz--2IC.;N hCIAN A-ksK.AN AS1AWPAC I N T{'1t SL►NCEA BLACK I }i153sJ+iC I WMrTE Clavton Carter 3 II ' 1 23 383 C. Rawlings Community Center 6 6 35 1 1,605 I 757 Rodgers Community Center 7 19 45 1 8?4 739 I !4ae Simmons Community Center 3 0 783 237 87 Woods Community Center Z ' - - --- 1 , 746 i 1,060 113 census _. Oces t~e organization rave scec,`c .7--emze--;n e rar,'s '+�r.ic.-t result in tha der. al cf prograrn dene,;ts to s,:ecifc ;scups? ................................. . ............ . . ............... Yes X _ ,f aes, tescr:te t~-csa sepal-er*Fna: ..`a:.:n :C .-C a.� 'Z515 CC'S rJ7-1t=„:CAS E:A: _Zx--7_.. ^f y 1 -- .._:e - - - �u�.� its:, D.s.3., eiiar�, word-c- M -,Idth _. 'eVrlgt der �:LtCeazn .,CCs W' I Ce =Kcn �`� .�? ' o C l . s Sl'? ...a: 'Gn.s ,.."e _'2a _ _ V'I:.', an ecuaf �ppert;.nlry :o Via, ;c:ca:a .n .-e _ �. Has any federal agency nc;reo —e C 7anlzat:Cn :t 'Cr-- cm-'{iarce with :nee C;vfl R:gn:s a- Cf 196:0 . ............. � Yes if yes, give detaiis irc`.LCirg dates, names, artd res4r:s: REHAMLiTATiON ACT OF 1973 (Seotlon 504) A. Dces "e wntrac:,rig cr,ar,za.,en rave any x.ic:es. cra^;ces, cr arcr�tec :'ral tartars .~at ;rrlt. cen.y, :r cisc.^,urage ^.ar:c'zaGCn In ins pr grant or em:Zvr art ; Y ;`e =rasa'.,^_ Ct_arazat'Cr ........ Yes if `+es, explain: "•s,as Deparwnerd Form IS07/f)e.-.amtWr '?.. "" rnan Serelaes SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR DHS USE ONLY SITE INFORMATION TX I -OR EU '.ame of Food Service Site Teieprwne No- (mc. W) Clavton Carter N/A park site caress of Site (Street. City, State. ZIP) Globe and N. Lopp 289, Lubbock TX 79403 � erwd of operation of Foal Service (mojdaylyr,-mjdaytyr,) Number of Op- A May J� June Jul Aug. Sept. From: 6105095 through: 8-11-95 eratingDays: rW 0 �j) 20 20 9 0 ,TTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children tither She 1. Indicate Type of Site: ❑ A,(serving one to four meals) ❑ C. (serving one to four meals) E. (serving one to tour meals) Nonresidential Camp Site Serving Primarily Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving one to lour meals) 2. List ALL counties served by this site: Lubbock 3. A. Is your site open: ....................................... ... Des ❑ N c B. Is your site enrolled? ............................................. _........._............._..................._...... ❑ Yes 7 N c C. Site Eligibility: Enter the percentage of children eligible for free ar4or reduced price meals for the site (SFSP Handbook. Chapter II).... 91 ' r' D. If open sites, submit documentation supporting this percentage figure (such as census date, school data). For open sites using school =2 list the schools used to document site eligibility; attach formula used by school dist, to establish percentage of free & reduced price ch.ldrer. Arnett Eiemntary E. For enrolled sites, Form 1531 will be used to document eligibility. If the enrolled site used school data, list the school used to document the site: F. What is the percentage of free or reduced -price meals for the site? ............................ .................... 4. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter 11)..... . . . .... . . , ......... , Des U tic If Yes, give name of contracting organization: Luhboc: 5. Monitoring Plan (SFSP Handbook, Chapter 111): Enter date of monitoring review to be conducted within: A Fist week d Dperawn S. First Four W wks of Operation C. Additional Reviews b-5-95!6-9-95 6-5-95/6-30-95 6-5-95/8-11-95 6, Meal Service Period Information (SFSP Handbook, Chapter II): TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 30 12:15 p.-n. 1:30 p.m. P.M. Supplement Supper •Tim ._.__�� ._ ��.,....�.. W fYJC ..�......�.�..... .iw� �......�...' w��l .�.,�.,� Lw..�l lCCCG 41�MIw.1. f w....��. If\ 7. Do you plan to feed children under one (1) year old? ... . ................ .. []Yes C INC S. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11) Se1I-PrapsrW " vended Using School Using Food Service Management Using Private Non -Profit 4n site ❑ Central Kitchen I ❑ Food Authority U Company (Includes All Year Contacts) 0 Organlzation that Is Sell-Prtrp w 00I)WIln.rrt Form t sdh.31 }fuwt ' son4°" SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR OHS USE ONLY SITE INFORMATION TX E - . Fri R amr of Food Sel RZ;; No. (WV—.Chats!S«sees PAe ark n/a park site dress o1 Sao (Street city, Stale. ZIP) 27th and Ivory Lubbock TX 79404 ,nod of Op"bon e1 Food Service (ru+olaeytr--fmjd&W-) Number of Op- 6 way j1* Aug- =rom: 6-5-95 through: $-11-95 eratingDays: Y Q j' 20 >rl t 9 f C TTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Carp Site Serving Prlmargy Wgrant Children Other Site 1. Indicate Type of Site: ❑ A. (serving one to lour meals) ❑ C. (serving one to tour meals) E. (serving one to tour meals) Nonresidentlal Camp Site Serving Priniarity Homeless Children ❑ B. (serving one to four meals) ❑ D. (serving one to four meals) 2. Ltst ALL counties served by this site: Lubbock 3. A. Is your site open: ................................... . — -............................................................ zYes C No B. Is your site enrolled? ........................................ . Dyes E-No C. Site Eligibility: Enter the percentage of children eligible for he andlor reduced price meals for the site (SFSP Handbook. Chapter lo.... % D. If open sites, submit documentation supporting this percentage figure (such as census date, school data). For open sites using school cata, list the schools used to document site eligibility; attach formula used by school dirt to establish percentage of free & reduced price chiic en SzeaEiey aieitrEs it E. For enrolled sites, Form 1531 will be used to document eligibility. If the enrolled site used school data, list the school used to document the site: F. What is the percentage of free or reduced -price rneals for the site? ..................... . .......... . . ....... . . . .. . . . '� 4. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter Iq, , . ... . ......................... koalYes C No C; r o= Lu»ack if Yes, give name of contracting organization: 5. Monitoring Plan (SFSP Handbook. Chapter I11): Enter date of monitoring review to be conducted within: w Fmt, weak of Operation r3. First Four weeks of operation C. Addbonaf Reviews 6-3-95/6-9-95 6-5-95/6-1n-95 6. Meal Service Period Information (SFSP Handbook. Chapter If): TYPES OF MEAL NUMBER OF EUGiBLE CKLDREN To BE SERVE? MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 75 12:05 p.m. 1:15 o.m. P.M. Supplement Supper 7. Do you plan to feed children under one (i) year old? ............................................ . ........................ ❑Yes E Nc S. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter II) s.u-rr.pa.auon Using School sing Food Service Management Using Private NmProfd []On Site ❑ Central Kitchen I ❑ Food Authortty Nf ucompany (Includes All Year Contracts) ❑ Organiation that Is Self-grt: ,_" D"11011fir-y Form 7 sd7 mRw - � ~.mrmn Servft'a SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR me USE ONLY SITE INFORMATION TX R No oov�aa C = , under OVS!� Park in/a/parksite #� 3drsss of SAe (Sw0' Cuy. Sulu, Zip) 1st and Temp 1e - Lubbock TY 79415 �-)od ofration of Food Sary a (mo *&Yfr -m Jdayto) Nurr►bet of �""a ' �. sw From* 6-5-95 through: 5-11-95 erating Day 4 4 �0 9 ,7ACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp She Serving Primarlly Migrant Children Other Site 1. Indcate Type of Site: ❑ A. (serving one to four meats) ❑ C. (servhv one to lour meals) E. (serving one to Iota meals) Nonresidential Camp Site Serving Prinurily Homeless CWMmn ❑ S. (serving one 10 bur meals) ❑ D. (serving one to bur meals) i_'.lbbocic 2. List All counties served by this site: 3. A. Is your site open:.......................................................I......................_.........._........... Yes ❑ N o B. is your site enrolled? _ .. _ ....... []Yes h� C. Site Eligibility: Enter the percentage of children eligible for hee andlor reduced price meats for the site (SFSP Handbook, Chapter 11)... . D. If open sites, submit documentation supporting this percentage figure (such as census dale, school data). For open sites using school da•_ list the schools used to document site eligibility-, attach formula used by school dist to establish percentage of free & reduced price childre- Jack-s.-n 1eneatary E. For enrolled sites, Form 1531 will be used to document eligibility. If the enrolled site used school data, list the school used to document the site: F. What is the percentage of free or reduced -price meals for the site? ....... . . . ............. . . _ ............. ° : a. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter 11) ............................... . ....... . .. QYes []No C'_ ty o ` Lubbcc.k tf Yes, give name of contracting organization: 5. Monitoring Plan (SFSP Handbook. Chapter 111): Enter date of monitoring review to be conducted within: A_ Frsl Week d Operabon S. First Four weeks of Operabon C. Addoonal Royiewi —� 6-5-95/6-9-95 1 6- 95/6-30-95 1 6-�-95/8-11-95 6. Meal Service Period Information (SFSP Handbook, Chapter If): TYPES OF MEALS NUMBER OF ELIGIBLE CKLDREN TO BE SERVED' MEAL SERVICE TIME BEGWNrNG ENDQiG Breakfast A.M. Supplement Lunch ?) 11:40 a.m. 12:45 pm. P.M. Supplement Supper 1 MS EVOrma u" 4 4u*aAA"WU V1 vn WNW" s V _ ,.,. . o._ rv. .. .,vw.ti ...-4— .., 1171 T. Do you plan to feed children under one (t) year old? ..................... . .................. . .... . . ❑ Yes " No S. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11) Sed-PrepWabon vended Using Sehool U" Food Service Management U&IN Private Nor�rord ❑ On Sae ❑ Central Kitchen ❑ Food Authority U Company (Includes All Year Contracts) ❑ Organization that Is Self -Prep , w Dep"ryry come 7 SD7 ' ?' SerAws SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR ONS USE ONLY SITE INFORMATION TX .m. of food sornm Site 0*PNM No. (tie Burns Park nfa Bark site sd.eu of SAe (Street. City. State, ZW) 23rd and Ave. L — Lubbock TX 79405 anod of operation of food suvroe (—JdaYfYr--+rtoldaYM•) Number Ot Op` May `ur" July 'M From: 6 7-9� through: 8-11-95 eralingDays: 0 20 20 9 0 TTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Aesldential Camp Site Serving Prfmarty Migrant Children Other Slte 1. Indicate Type of Site: El A. (serving one to four meals) ❑ C. (serving one to four meats) La E. (serdng one to bur anus) Nonresidential Camp SU Servlrig Primarily Homeless Children ® B. (servbv one to four meats) ❑ D. (semrtng one to tour meals) Lubbock 2_ List ALL counties served by this site: 3. A. is your site open* ..................................................................................................... myes ONO B. Is your site enrolled? . . ...................... . ..................... •...................................... • . ........ ❑Yes []No C. Site Eliigibitity, Enter the percentage of children eligible for free and/or reduced price meads for the site (SFSP Handbook, Chapter II)... . 95.E D. If open sites, submit documentation supporting this percentage figure (such as census date, school data). For open sites Cuing school data list the schools used to document site eligibility; attach formula used by schW disc. to establish percentage of free b reduced price cht7dw-, Bean Elemen[ary E. For enrolled sites, Form 1531 w111 be used to document eligibility, It the enrolled site used school data, list the school used to document the site: F. What is the percentage of free or reduced -price meals for the sfte7..... . ...... . . . ... . ... . ...... ....... . ..... ...'; 4. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter If) . ......................................... syes []NO If Yes, give name of contracting organization: Ci t . ��f Lubbock 5. Monitoring Plan (SFSP Handbook, Chapter III): Enter date of monitoring review to be conducted within: A F rst week Of Operatrm �. First Feu weeks of OF enum C. Addimonaie i Revws 6-5-95/6-9-95 6-5-9516-30-95 6-5-95/3-11-95 � 6. Meal Service Period Information (SFSP Handbook. Chapter It): TYPES Of MEALS MIrUSER OF ELIGIBLE CWLDREN TO BE SEAVEIr MEAL SERVICE TIME 91GO9I NG ENDONG � Breakfast E A.M. Supplement Lunch 75 _:4 am 1:00 m P.M. Supplement Supper 'Tres "onilamon is ODrMAOW*d VY UKI %TM ""KV vw "I'W a;+ meal >R M ` %Q'O' rwaiv n, t,+ ++n 11J 7. Do you plan to feed children under one (1) year old? ................. ...................... ❑Yes C Nc S. Method of Food Preparation by Contracbng Organization (SFSP Handbook, Chapter 11) Sew-P�n vendea U:Ing School sing food Service Management Using Private Non-Profd r] On Site ❑ Central Kitchen ❑ Food Authority Company (Includes Alf Year Contracts) ❑ Organization that is Sett-Prry 23 Depervnera Flom 1Sf7712nnt! 1e94 ``"""' g'"fML01's SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR Z*d USE OfiY SITE INFORMATION .X R L -w a Food Ser"M SAO Telephorw No. 4r+� Pioneer Park x"sa of Sib (5t"Mt. CeY. Stow. ZIP) 6th and ?.ve.T- Lubbock, TY 79401 I od of bon d Food Swvke (moJdayfYf--n d&YtrJ TNumbar of f)p- May June �� �AW. SOOL �1 •0m:6-5-95 through: 8-11-95ntingDa0 20 y �0 9 0 h TACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Res$dential Camp Site Serving Primarily Migrant Children 00W She Indicate Type of Site: ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) knj E. (serving one to four meals) Nonresidential Camp Site Serving Prlfnargy Horneiess ChOdren ❑ B. (serving one to four meals) ❑ D. (serving one to lour meals) Lubbock List ALL counties served by this site: 3. A. is your site open :. . .. . ................ . . . ........... . . . ....................................................... 10Yes []No B. is your site enrolled? ....... . .................. ......................................................... . ❑Yfes td, Nc C. Site Eligibility- Enter the percentage of cNldren eligible for free and/or reduced price meals for the site (SFSP Handbook. Chapter IQ.... D. If open sites, submit documentation supporting this percentage figure (such as census date, school data). For open sites using school da:a list the schools used to document site eligibility, attach formula used by school disl. to establish percentage of free & reduced price ciikrer Ramirez Elementary E. For enrolled sites. Form 1531 will be used to document eligibility. If the enrolled site used school data, list the school used to document the site: F, What is the percentage of free or reduced -puce meals for the site? ... ... � . .... . ............................. . ....... ` �. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter IQ .......... . ............................... Yes [ISO if Yes, give name of contracting organization: -i tv of' Lub'boc'r_ 5. Monitoring Plan (SFSP Handbook, Chapter ill): Enter date of monitoring review to be conducted within: A. Fist week of Operaoon e. Fsst Four weeks of Ope.soo., C. Addhonall PANIOrrs 6-5-95/6-9-95 6-5-95'6-30-95 6-5-95/3-11-95 6, Meat Service Period information (SFSP Handbook, Chapter II): TYPES OF MEALS NUMBER OF ELCMLF CHUMREN TO BE SERVED" MEAL SERVICE TIME BEGINNING ENdO'1f3 Breakfast A.M, Supplement Lunch 135 11 5 0 ant 1: 30 otn P.M. Supplement Supper 7. Do you plan to feed children under one (1) year old? ............................ ......................................... ❑Yes El No S_ Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11) Sod-prgMsriw+ 11"id" Using School Using Food Service Management Using Private Non-Prord Mon Stte 0 Central Kitchen I ❑ Food Authority 2 Company (Includes All Year Contacts) ❑ "antutlon that Is Self -Prop I" Depenmrnl burn 1 19.44 H*.~ Se AM$ SUMMER FOOD SERVICE PROGRAM FOR CHILDREN Fon MO UW ONLY I SITE INFORMATION TX , E �w�.5� R U � Affm dCarlisle Park n%aPark Site i 'O"s of Sae (Street. City. Stall. Z*3) 25th S AVe W. Lubbock, TX 79411 *nod of 05watpon or Food Sorvice inioldayro. w.y1y�)=0rijaUng mber of O May June J' Aug- Seri. From: -5-95 through: -11-95Days: � 0 70 L0 9 0 TTACH A MAP WrM THE SITE SERVICE AREA IDENTIFIED Residential Camp She Serving Primarily Migrant Children Other Site 1. Indicate Type of Site: ❑ A. (serving oee to four meals] ❑ C. (serving one to lour meals) CR E. (serving one to bur mesh) Nonresidential Camp Site Serving Primsrtly homeless Children ❑ B. (serving one to bur meals) ❑ D. (serving one to four meals) Lubbock 2. List ALL counties served by this site: 3. A. Is your site open: ................................... ....... ....................................................... - Yes ❑No B. Is your site enrolled?........................................................ . ... . .... . .......................... . .... [Dyes 1� No C. Site Eligibility. Enter the percentage of d*ren eligible for free andlor reduced price meals for the site (SFSP Handbook, Chapter 10.... CIO D. If open sites, submit documentation supporting this percentage figure (such as census date, school data). For open sites using school da:a fist the schools used to document site eligibility attach formula used by school disc. to establish percentage of free & reduced price chkren. Dupree Elernenary E. For enrolled sites, Form 1531 will be used to document eligibility. If the enrolled site used school data, fist the school used to document the site: F. What is the percentage of free or reduced -price meals for the site? .. . ............ . ...... . . . . . .... . .............. . 4. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter ID.... -... , . , Yes [INC If Yes, give name of contracting organization: i t V Of Lubbock 5. Monitoring Plan (SFSP Handbook, Chapter 111). Enter date of monitoring review to be conducted within. A- Frst WeeK ar OWaW B. Frit FoLr Weeks or OpwUon C. Add0onal Fievis 6-5-95/6-9-95 1 6-5-95/6-31-05 6-5-95/8-11-95 I 6. Meal Service Period Information (SFSP Handbook, Chapter 11): TYPES OF MEALS NUMBER OF ELIGIBLE CKLDAEN TO BE SERVED' MEAL SERVICE TIME BEGIfooNG , ENDM Breakfast A.M. Supplement Lunch 60 11:30 am 1": '5 Pm P.M. Supplement Supper - 1 ros /11omwm-n 4 UUMOWWea 67 u. v w, —, --y r— -14— w — %- —. ,--.......- --' "I 7. Oo you plan to feed children under one (1) year old? ..... ........................................ ........... ............. ❑Yes t4fNc 8. Mettiod of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11) 304F 0 VWx*d Using School sing Food Service Management Us41g Private Mon -Profit non Site [l Central Kitchen I ❑ Food Authority Company Cincludes All Year Contracts) ❑ Organization that is Seff-prep jks Depwvneo Forte 1S07RaeKsrtiDer i9?e SWAMI SUMMER FOOD SERVICE PROGRAM FOR CHILDREN RM"USEONLY SITE INFORMATION ,X R u » or Food Serum Sm eleph" No. @me- Roogers Community Center (806)767-2702 <OU of Silo (S"Ot, Cay. Stale, ZIP) 3200 :1mhe rs t cod oloperation of Food Service (moldeylyr--Mjdaylyr.) � } UsY 1�+�� A July Aug 6-5-95 S-1 -95 Number of tTJ 0 �� t]% ?!1 9 0 'oel: through: eating Days: -TACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children Outer Sire Indicate Type of Site: ❑ A. (serving one to four meals) ❑ C. (serving one to four meals) E. (serving one to four meals) Nonresidential Camp Site Serving Primarily Homeless Children ❑ B. (serving one to bur meals) ❑ D. (serving one to lour orals) Lubbock List ALL counties served by this site: 3. K Is your site open: ................... .................................................................................. Wyes ❑ No B. Is your site enrolled? .. . ...... . ......................... . ................. --Oyes O N o /g. f C. Site EI•lgibility: Enter the percentage of children efigible for free ardor reduced price meals for V* site (SFSP Handbook Chapter 11)... . O,a D. It open sites, submit documentation supporting this percentage figure (such as census date, school data). For open sites using schoa data, list the schools used to document site eligibility, attach formula used by school dist to establish percentage of free & reduced price chkrer,. McWhorter E1ementary (90,5) Tubbs Elementary (65,2) E. For enrolled sites. Form 1531 will be used to document eligibility. If the enrolled site used school data, list the school used to document the site: F. What is the percentage of free or reduced -price meals for the site?, , ....... _ all, Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter IQ . . ........................................ MYes ❑ No Cite Lubbock If Yes, give name of contracting organization: 5. Monitorino Plan (SFSP Handbook, Chapter III): Enter date of monitoring review to be conducted within: A. Fvst week of Operation B. First Far weeks of Openwon C. AddUx%i l Aenews 6-5-95/6-9-96 6-5-95/6-30-95 1 6-5-95/8-11-95 6_ Meal Service Period Informabon (SFSP Handbook, Chapter UI): TYPES OF MEALS NUYBER OF El_tGM E CKLDREN TO BE SERVEIr MEAL SERVICE TIME BEGWNWG EMDWo Breakfast A-M. Supplement 4 Lunch lei) 11:30 am 1 :00VM P.M. Supplement I Supper 0- roc ,.,f— . n. N,.:,,,, m-61 —id � W, l rczca k2rv* --k n"w in 7. Do you plan to feed cNidren under one (1) year old? ............ . _ .... Dyes n No a_ Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11) SO P"Wat1 n 1en°"o Using School sing Food Service Management Using Private Non-Prold n on Slte 0 Central Kitchen I ❑ Food Authortty 21company (Includes All Year Contracts) Q 0ryanUZ21lon that Is Sett -Prep us Depewnsed -lurnm S'"viO`s SUMMER FOOD SERVICE PROGRAM FOR CHILDREN SITE INFORMATION "• oLFvod S im,�sans+«. `1ae s Community Center Dads of Saa (Sve* . G+y. state. ZIP) 23rd and Oak - Lubbock, TX 79403 Fam, rsdrpp=n *. • 9-=1 FOR OKS USE ONLY tI L MM No. (ft- AOq 06)767-2700 ,,rod of L"mhan of rood 5>Gev" (molwyj r—rn twyr9'r•) Number of Op- 6 "my 5"X prom:6-5-95 through: 8-11-95 entingDsys: 0 2n 20 9 0 rTACH A MAP WtTH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children Other Sit. Indicate Type of Site: ❑ A. (ser dng one to tour meals) ❑ C. (serving one to four mesh) WE. (serving one to four m ah) Nonresidential Camp Site Seryrfm ing Partty Homeless Chiidran ❑ S. (serving one to four mesh) ❑ D. (servlrg one to four meals) '. list ALL Counties served by this site: 3. A. 13 your site open: .............................. . .......................... ............................................ W Yes ❑ No B. Is your site enrolled? .......................... . ...................... . .. ❑ Yes No C. Site Eligibility: Enter the percentage of chadren eligible for free w4or reduced price meals for fhe site (SFSP Handbook, Chapter 10.... 8 7 . D. If open sites, submit documentation supporting this percentage figure (such as census date, school data). For open sites using school data, fist the schools used to document site eligibility; attach formula used by school dist to establish percentage of free & reduced price children,. Pose,: Elt2mentary E. For enrolled sites, Form 1531 will be used to document eligibility. If the enrolled site used school data, list the school used to document the site: F. What is the percentage of free or reduced -price meals for the site? ........... _ ..... . I ......... ..... . . . ............ ' �. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter 11 .................... ...................1. Yes ❑ No If Yes, give name of contracting organization: City of Lubbock 5. Monitoring Plan (SFSP Handbook. Chapter 111): Enter date of monitoring review to be conducted within: A, Fwsl Weak of Operabon 8. Frst Four Weeks or Opombon C. Addoo ail PAr4 as 6-5-95/6-9-96 6-5-95/6-30-93 6-5-95,18-11-95 6. Meal Service Period Information (SFSP Handbook. Chapter IQ: TYPES OF MEALS NUMBER OF ELIGIBLE CHILDREN TO BE SERVED' MEAL SERVICE TIME BEGROXNG ENDING Breakfast A.M. Supplement Lunde 125 12:15 prm 1:30 pm P.M. Supplement Supper .�►; _.�_.� _ ..,...:A-4 a., MOO wdh n ..e.,n &16 kfaE A MA21 "reWM brel_ rSFSP Kuvlhnnk manner in 7. Do you plan to feed children under one (1) year oid?..................................................................... Dyes aN 8. Method of Food Preparation by Contracting Organfzatbon (SFSP Handbook, Chapter 11) Sod-Prwwsbon vanosa Using School sing Food Service Management Using Private Non-Profd M On Site []Central Kitchen I ❑ Food Authority Company (Includes All Year Contracts) ❑ organizaWn that is Seff-Prep A2 DOPWknMr Faun 150 r " 994 SUMMER FOOD SERVICE PROGRAM FOR CHILDREN FOR OW USE oPLY SITE INFORMATION TX . tt U �,. of Food Wme SAe ++•o+ ► O. (br- George `Moods CotnmunityCenter (806)767-2698 yeas a see (sveet. Gty, smis, ZIP) Zenith S Erskine Lubbock TX 79403 qua of kin of Food SerAmi (n,*Mytyr--wJdayJyr.) Number of Op. h I'nay ��"" �Y h Aug- hsqx _rom:6-5-9 through: 8-1 1-95 erasing Days: 0 �0 TACH A MAP WrrH THE SITE SERVICE AREA IDENTIFIED Residential Camp Site Serving Primarily Migrant Children Indicate Type of Site: ❑ A. (serving on@ to tour meals) ❑ C. (serving one to four meals) Nonresidential Camp Site Serving Primarily Homeless Chadmn ❑ B.(sefying one to bur meals) ❑ D.(serving one to four meals) '_. List ALL counties served by this site: Lubbock 20 0 Other Slte E. (serving one to bur auals) 3. A. Is your site open: ........... ....................... ......... ................................ ..................... ffy. ❑ No B. Is your site enrolled? . ................................. . .......................... . ...... ❑ Yes n No C. Site Eligibility. Enter the percentage of children eligible for free andlor reduced price meals for the site (SFSP Handbook, Chapter lij.... 9 * % D. If open sites, submit documentation supporting this percentage figure (such as census date, school data). For open sites using school data, list the schools used to document site eligibility; attach formula used by school dist to establish percentage of free & reduced price children. Hunt Elementary (93.5) Parkway E1e-enary (94.6) E. For enrolled sites, Form 1531 will be used to document eligibility. If the enrolled site used school data, list the school used to document the site: F. What is the percentage of Iree or reduced -price meals for the site?... . 8,2 4. Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter li). . . . . ............ . . . ... . ... . .. . .......... ElYes ❑ fio it Yes, give name of contracting organization: Cit.: c � 5. Monitoring Plan (SFSP Handbook, Chapter 111): Enter date of monitoring review to be conducted within: A. Fist Week of Opetabon a. Firy Fax Weeks of Opwatson C. Addit"W PAvwws 6-5-95/6-9-95 1 6-5-95/6-30-95 1 6-5-95/8-11-95 6. Meal Service Period Information (SFSP Handbook, Chapter II): TYPES OF MEALS 11A1MBER OF ELIGMLE CHILDREN To BE SERVE? MEAL SERVICE TOE eECtNNINC ENDING Breakfast A.M. Supplement Lunch 70 12 : 3') pm 2 : ')Opts P.M. Supplement Supper IIY{ fYa frwqu w a UWCW_,,WWU ur v.w „�,e,. ,o.,,.y ,... wr....,.....�..o.......,n.. y.,. v . w.,.......a ...+v.o...� 7. Do you plan to feed children under one (1) year old? ........................................... . ..... .. L `Yes q'Nc .................. 8. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter 11) S 4114`r &Wn V0', Using School using Food Service Management Using Private icon -Profit ❑ On Site [:]Central Kitchen ❑ Food Authority �Smpany (Includes All Year Contracts) ❑ Organization that is Seft-Prep us 06owtrrerM Hwima r serAm SUMMER FOOD SERVICE PROGRAAA FOR CHILDREN SITE INFORMATION vne CoppSWAP* So" er Kgwiings Community Center Faun Isd7)Oeoerft +9c" FOR DNS Use ONLY 00 R 6�) 4 ;ones on 511111e (Svee[, k-1117. ZbumI urn 40 th & Ave. B a,,00 a abon of Food Swyk:o (Ma de t r.—VJdaYM) Numbef of may �" �A* Ar+O Fromb-5-95 through: 8-11-95 ers0ngDays: 0 20 20 9 �0 rTACH A MAP WITH THE SITE SERVICE AREA IDENTIFIED Resklentlal Camp Site Serving Primarily (Migrant Children Ottxr S4e 1. indicate Type of Site: ❑ A. (serving one to four meals) ❑ C. (serving orw to four meals) E. (serving one to bur meals) Nonresidential Camp Sloe Serving Prlmarly Homeless Children ❑ e. (serving one to W meals) ❑ D. (serving one to four meals) 2. Ust ALL counties served by this site: Lubbock 3. A. is your site open: .................................................... . ........................ . . ...................... Yes ❑ No B. Is your site enrofled? .......... . ................... ................... .................... Oyes ONO C. Site Eligibility, Enter the percentage of children eligible for free andfor reduced meals for the site SFSP Handbook, 99.4 g tYY Pe fl �9 itrioe ( Chapter !f)....11, D. It open sites, submit documentation supporting this percentage figure (such as census date. school data). For open sites using school da:a, list the schools used to document site eligibility: attach formula used by school dirt. to estabksh percentage of free & reduced price Children. Harwell Elementary E. For enrolled sites, Form 1531 will be used to document eligibility. If the enrolled site used school data, list the school used to document the site: F. What is the percentage of free or reduced-pnce meals for the site?, ... ..................... .. .... . ............ ... 4, Did the site participate in previous years' SFSP? (SFSP Handbook, Chapter It) ... . ... ................................... eyes [} Nc If Yes, give name of contracting organization: tit': of Lubbock S. Monitoring Plan (SFSP Handbook, Chapter 111): Enter date of monitoring review to be conducted within: Frsr Week of operaton B. Frsr Four Weeks of operation e;. Aodoo" Nrmws 6-5-35/7-9-95 6-5-9516-30-95 6-5-95/8-'-1-95 � 6. Meal Service Period Information (SFSP Handbook, Chapter II): TYPES OF MEALS MMSER OF ELIGIBLE CWLDREH TO BE SERVED' MEAL SERVICE TIME BEGINNING ENDING Breakfast A.M. Supplement Lunch 125 11:30 am 1:30 pm P.M. Supplement Supper .,L — - —4-4 +.,, rues, when e:.n.,e tti aeern`rd mo.+ 2AM" WnMl ISFsa HArehnak_ r"s,anrW in 7. Do you plan to feed children under one (1) year old?..................................................................... © Yes ® No B. Method of Food Preparation by Contracting Organization (SFSP Handbook, Chapter If) so-Prepwabon Vende4 Using 5ehool Using Food Service Management Using Private No*-Prord ❑ On Site ❑Central Kitchen i ❑Food Authority Company (includes All Year Contracts) ❑ Organtrallon that Is Self-Preo SUMMER FOOD SERVICE PROGRAM AGREEMENT STATE OF TEXAS § COUNTY OF TRAVIS I The Texas Department of Human Services, hereinafter referred to as TDHS, 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 (Section 13) and the Summer Food Service Program, hereafter referred to as the SFSP, Federal Regulations (7 Code of Federal Regulations tCFR], Part 225). I. NfUTUAL AGREEMENTS The Parties mutually agree: A. If the contractor fails to provide services in accordance with the provisions of this contract, the Department may, upon written notice of default to the contractor, immediately terminate the whole or any part of this contract and refuse to pay claims for reimbursement. Such termination and/or refusal to pay claims for reimbursement shall not be exclusive remedy but shall be in addition to any other rights and remedies provided by law or under this contract. B. If federal and 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 or obligations, including audit findings, incurred up to the date of termination. C. This contract may be canceled by mutual consent. However, if such mutual consent cannot be attained, then and in that event, either party to this contract may consider it to be canceled without cause by giving thirty (30) days notice in writing to the other party and this contract shall thereupon be canceled upon the expiration of such thirty (30) day period. Nothing in this paragraph shall be construed to prohibit immediate cancellation pursuant to above paragraphs A and/or B. IV. CIVIL RIGHTS POLICY COMPLIANCE A. The contractor agrees to comply with Title VI of the Civil Rights Act of 1964 (Public Law 89-352), and all requirements imposed by the regulations of the Department of Agriculture (7 CFR, Parts 15, 15a and 15b) Department of Justice (28 CFR, Parts 42 and 50) and USDA and TDHS directives or regulations issued pursuant to that Act or 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), 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 persons in the Untied States shall, on the grounds 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 under any program or activity for which the contractor receives federal financial assistance from TDHS and USDA: and hereby gives assurance that it will immediately take any measures necessary to effectuate this agreement. B. The contractor agrees to comply with Texas Revised Civil Statutes Article 4419b-4, Sections 5.03 and 5.04 (relating to workplace and confidentiality guidelines regarding AIDS and HIV). C. This assurance is given in consideration of and for the purpose of obtaining any and all federal financial assistance, grants and loans of federal fund, reimbursable expenditures, grant or donation of federal property or interest in such 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 contractor by TDHS. This includes any federal agreement, arrangement, or other contract which has as one of its purposes the provision of assistance such as food, cash assistance for the purchase of food, rental of food service equipment or any other financial assistance extended in reliance on the representation and agreements made in this assurance. D. 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 TDHS or USDA. The person whose signature appears- on this contract- is authorized to make this assurance on behalf of the contractor. 0 TDHS CLAIMS PAYMENT TDHS will, subject to the federal appropriation and availability to TDHS of sufficient funds for the SFSP, make program payments to the contractor in accordance with the terms of this contract. No reimbursement shall be made for performance under this contract occurring prior to (a) the beginning effective date of this contract or (b) a later date established by TDHS based on the date of receipt of a fully executed copy of this contract. Non School Sponsors - Page 3 YI. CERTIFICATIONS (continued) 7. 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. 8. 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 Department of Human Services may pursue available remedies, including suspension and/or debarment. C. 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 $ 100,000 for each such failure. The contractor certifies, to the best of his or her knowledge and belief, that: 1. 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. 2. If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting to - influe= an officer 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, subgrant, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. 3. The contractor shall require that the language of this certification be included in the award documents for all covered subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all covered subrecipients shall certify and disclose accordingly. 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. Non S, hool Sponsors - Page 5 ADNDNLSTRATION Administrative Labor 1. Special Programs Supervisor (Paula Simpson) Director of Program Budget Preparation 12 hours Budget to Council and Park Board 8 hours Developing Training 6 hours Site Inspection 6 hours Ordering Supplies 10 hours Conducting Monitor and Site Supervisor 15 hours Personal Training 15 hours 69 x 13.23 = 913 4 hour/ day x 49 days = 13.23 hours x 196 hours 2593 3506 2. Assistant Director Training Developing Training Manual Preparing Orientation Hiring Site Staff 2 hour/day x 49 days = 98 hours 98 hour x 14.72 hours = $1443 4. Monitor Four (4) hours/day x 10.62 hour x 49 days = 2,082 Site Inspection Personal Training Site Supervisor 8 hours 2 hours 12 hours 10 hours 32x 14.72=471 $1,914 8 hours 4 hours 4 hours 16 hours x $10.62 = $170 Mileage 40 miles per day x .30 x 49 days = 588 Administrative Labor----------------------------------------7,672 Fringe Benefits $5,420 (FT Salaries x .25 ( Benefit Package) - 1,355 Office Supplies ($650 General Supplies) OPERATIONAL COSTS BUDGET Program Labor Playgrounds Six (6) sites 2 personnel (sum roc workers) x 2 hours x $5.10/hr x 49 days = $5998 Community Centers Four (4) sites x 2 personnel (asst.) x 2 hours x $5.44/hr x 49 days = $4265 Community Centers: Fringe, Food Rodgers - hours x $10.32 x 49 days = $506 Simmons - hours x $11.81 x 49 days = S579 Rawlings - hours x $10.32 x 49 days = $506 Woods - hours x $10.32 x 49 days = $506 2 097 Program Labor 52,097 PT $10,263 x .0765 Soc. Sec. = $785 FT $3,015 x .25 Benefits = $524 Fringe Benefits = $1,309 850 meals x 49 days x $1.75 = $72,888 Non Food (Plastic trash bags, tables, coolers, thermometers, hoses, wastercouplers, brooms, dust pans) Non- Food = $2,345 Page 1 `, fL[E�t1 Ont- -':�RAi�ts�i3'». PY COM TLC DMn Dent, of Human Seri ' �.} June 5-August .t 1. Is toles grant New Continuing x Number of Years 6 2. Is a match required? Yes No x If yes: Percentage Arntiount Is it In -kind 4R Cash Source 3. Are there any indirect costs, i.e. building use, c onVuter time, administrative supervision, associated with the grant? Yes x No If yes, tease list the estimated costs. 5,420 - Personnel 650 - General Supplies 6,070 - Total Indirect Cost 4. If there are indirect casts, are they reimbursed by the grant? 5. Are audit costs reimbursed? If yes: Yes x Percentage Yes Percentage No No x a. W tat are the audit requirements for this grant? Only a copy of the City's annual audt cf the grant is required. No special or specific audits are required. 7. Can this grant be renewed? If yes, how many limes? What are the terms of renewal? Yes x a. Does the grant require the City to gradually assume the cost of the program? Yes If yes, what is the timetable? IM. No x 1 r r1 V f i./ •J fr L. 6 r rr i V M l i `411 r V i uv! Pape 2 9. P*aw address whettwilr other agend" we currently adriwAnering simian programs and whettwr any oe w spende+s am mdable lo admmWer this progriarrL Due to the 1 1 sn i ted Rdm_1_n Lstrat i on e I mbursem rat w I th th i c „,rogram, other agencle_s are not Interested in the program. The City combines- grantt with the Summer Satellite funding which enables us to provide the service. Other agencies may be Interested If they can overate both ❑roarams, we wlII tg aak lnng agencies of their Interest for next year. 10. For the 'Current Year, please identity how expenditures are to be made in the towing wing categories and how the program wa be funded. tf the grant is for an on -going program, please prujW revenue and expenditures to fu me years. It the grant is kw one yew, show any omloirq costs to the City, such as the cost of mawftnance on equipment purchased by the grant . EXPENDITURES Personnel Full Tune Salary TWIRS Social Security Health Life Dental supplies Maenbenance Other (food) Capital TOTAL EXPENDMURES REVENUE Fed&W Grant SUft Grant Local Ma" Other TOTAL REVENUE CURRENT FUTURE YEARS YEAR 19 19_ 19, 19 19� 21,341 2 , 9 9,9(5 -0- 72,838 97,224 -0- 97,224 -0- 97,224 11. Please least the nurtiber and title (s) of personnel funded by this grant Twelve part-time re c r e a t io Supervisors at six park sites and eight part-time assistants at the community center for one hour a day to serve ]ttnnh_ 'There is also an existing full-time temporary p sit on to assist with -the program and monitor all sites on a daily basi . 12. P%me list any new positions to be added: N / A tie r�r� i ti 1 ► i v I V ry fi-` r r-% 6- V r, ► v a ... . P"s 3 13. Pkme rest any capital Kwm to be purchased: N / A 14. Pbase discuss how this program will impact current employee sB=bon and utkation and whether it wi l have a brg-term Wricial or manpower impact Attach additkxwl pages d needed. There will be 12 part-time recreation supervisors at the six park sites and 8 part-time assistants at the 4 community centers who will beworking with the summer lunch program. Impact of part-time personnel is 1,960 hours for this 49 day program. The part-timer personnel will supervise the summer programming at the 4 community centers and the 6 satellite sites after lunch is served. Impact of full -tine personnel is 2,689 hours for the 49 day program. This fugure includes the monitor who will also ..(see ATTACHED) 15. In nairrative forM please provide a brief desu"on of the program, Wlud'ng the need which will be addressed, tt►e goals and objectives of the program the target population to be served. and any other sgndk:ant aspects of the appkabon. Attach additional pages if needed. The City of Lubbock has participated in the Summer Food Program forthe last S years The program has been very successful. A daily average of 650 meals were served to children, ages 1-18 years, at 12 sites throughout Lubbock. The grant completely reimbursed all the direct costs (meal service personnel, sack lunches, and consumable supplies) and the indirect costs(meal service monitor, office supplies, and some administrative personnel expenses). With the past success of the Summer Food Program and a coninuing trend toward more basic human sercices within the City, (i.e. the successful Summer Satellite Playground Program and Butle Park Outreach Program (B-POP)and Rodgers Park Outreach Program (R-POP) for teenagers. The Sumer Food Program fulfills a vital need for Lubbock children during the summer. Funding from the Texas Department of Human Services will provide sack lunches for childrr,, at the following community centers: Mae Simmons, 23rd 6 Oak; Woods, Zenith & Erskine; Rodgers, 3200 Amherst; Rawlings, 40th b AVe B. The remaining six sites are Community Development Block Grant funded Summer Satellite Program sites: Carter Park, Globe and N. Loop 289; Carlisle Park, 26th & Ave W.; Chatman Park, 27th and Ivory; Pioneer Park, 6th and AVe. T; Burns Park, 23rd and Ave L; and Hollins Park, 1st and Temple. Administrative cost will be reimbursed for the Recration Outreach Coordinator and the Recreation Superintendant to manage the program. Fie '5 , gE DATE -- V _LC_ work with the summer satellite program. This figure includes the monitor who will also work with the summer satellite program. The hours reflected only include the hours for the summer lunch program. The monitor assist with the summer lunch program amd monitor the meal sites. This is an existing full-time temporary position.