Child and Adult Care Food Program

Forms & Resource Center

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Administration, Record Keeping & Finance
Income Eligibility
Number Name/Description Date Format
The following forms are for Fiscal Year 2020.
NS-402-G Income Eligibility Guidelines for FY 2020 – guidelines effective July 1, 2019 – June 30, 2020. 6/2019 2019-2020 IEF Guidelines
NS-100-C Income Eligibility Form – Child Care Centers – FY 2020 6/2019 NS-100C – Child Income Eligiblity and Enrollment Form FY20
NS-100-C Spanish Spanish Income Eligibility Form – Child Care Centers – FY 2020 NS-100C – Child Income Eligibility and Enrollment Form ES-US
NS-101-C Income Eligibility Form – Instructions – Child Care Centers 6/2019 NS-101-C FY20 Tip Sheet for Child Enrollment and IEF Final
NS-101-C.a Attachment to Income Eligibility Form to add more enrolled children or household members. This may not be used without NS-101-C. 6/2019 NS-100-C-a Additional Children FY20
NS-200-A Income Eligibility Form – Adult Care Centers – FY 2020 6/2019 NS-200A – Adult Income Eligibility Enrollment FY20
NS-201-A Income Eligibility Form – Instructions – Adult Care Centers 4/2016 IEF Adult Centers
NS-204-A Instructions to Households – Adult Care Centers – FY 2020 4/2016 Instructions to Households- Adult Care Centers – FY 2020
Alternate Translations of USDA Income Eligibility Form 4/5/2017 Alternate Translations of USDA Income Eligibility Form
Spanish translation – Income Eligibility Form 5/2011 Spanish translation – Income Eligibility Form
Pricing Programs: If you have a separate charge for meals, contact Nutrition Services for a different set of income eligibility letters & instructions.
Enrollment in CACFP
NS-105-C Child Enrollment Form – sample
children must be enrolled in CACFP annually
4/2015 Child Enrollment Form
NS-106-C Child Enrollment Form – instructions to centers 4/2015 Child Enrollment Form Instructions
Meal Counts & Claims
Record of Meals and Supplements Served (RMSS) – commonly referred to as “blue and white sheets” – 11″ x 17″ – request from Nutrition Services by email or phone (800) 731-2233 or (402) 471-2488 08/2006 Blue and White Sheets

11″ x 27″

NS-401-G Monthly Claim for Reimbursement Worksheet 04/2009 NS-401-G Claim Worksheet
NDE 28-017 Claim for Reimbursement – Child Care Centers 01/2011 Reimbursement Claim_Child Care Centers
NDE 28-018 Claim for Reimbursement – Adult Care Centers 04/2009 Reimbursement Claim_Adult Day Centers
Online Application and Claims
NDE 01-033 Computer Access Application and Agreement (application for ID and password) 06/2018 NDE-01-033computer-access-application-final
Training Registration Instruction Manual 03/2015 CNP Training Registration Manual
W-9/ACH IRS W-9 and enrollment for direct deposit of claim reimbursement 04/2014 W9/ACH Form
NS-407-G CACFP Agreement, Part II 04/2018 NS-407-G Program Application Permanent Agreement Part II 
Informational brochures and handouts
Getting Started on the CACFP – new sponsors/centers 09/2018 Getting Started on CACFP_web
Getting Started on CACFP_pdf
What to Expect – Getting ready for a compliance review or audit 07/2006 What to Expect
Signature Pages
NDE 01-017
Page 7
Certificate of Authority (change in responsible individuals/principals) 06/2019 NDE01-017-Cert-of-Authority FY20
NDE 01-017
Page 8
Organization Representatives Signature Page 06/2019 NDE01-017-Organization-Statement FY20
NDE 01-033 Computer Access Application and Agreement (application for ID and password) 04/2018 NDE-01-033computer-access-application-final
Food Service Contracts – procurement
NS-404-G Food Service Contract Fillable Form – Complete package – instructions, contract, regulations, all attachments 06/2018 Coming Soon
NS-404-G Food Service Contract – Complete package – instructions, contract, regulations, all attachments 08/2019 FSMC Contract Packet Complete 
NS-404-G Food Service Contract Attachment D- Addendum 04/2019 FSMC Contract Amendment Form fillable PDF
NEW! Sample Delivery Ticket 04/2019 Updated Sample Meal Delivery Ticket
Small Purchase Procurement (done annually) 05/2014 Small Purchase Procurement
Approved Vendor List 06/2017 Approved Vendor List
Federal Regulations Federal Regulations
IMPORTANT: All contracts in excess of $150,000 per year must be submitted to and reviewed by Nutrition Services before they can be accepted and signed by the CACFP institution. Allow at least 10 working days for Nutrition Services to review the contract.
Administrative Tools
Introduction to the CACFP – training manual for FY 2019 07/2018 Child care center-coming soon

Adult Care Center – Coming soon

NS-405-G Time Certification Worksheet – use this to document time worked in CACFP if needed to prove nonprofit food service operation 04/2009 Time Certification Worksheet_pdf
Time Certification Worksheet_excel
NS-406-G Sample Site Review form – for sponsors of multiple sites 04/2018 NS-406-G Affiliated Site Review Form 
NS-409-G Administrative Review procedures – steps for submitting an administrative review (appeal) regarding NDE actions 06/2017 Administrative Review Procedures
Nebraska Household Contact System (for sponsors of more than one site) 04/2005 NE Household Contract System
Sample household survey letter and form (for sponsors of more than one site – this letter could also be used as a basis for telephone contacts) 04/2005 Survey Letter and Form Sample
 NS-413-G CACFP Monthly Expenditures (use to track expenses) 04/2017 NS-413-G Monthly Expense Worksheet Rev March 17
CACFP Administrative Handbook – has your center participated on CACFP for several years? Is your CACFP 3-ring binder or part of it missing? 12/2011 Handbook Web Link
CACFP Handbook for Sponsors of Multiple Sites 11/2008 Multiple Sites Handbook
Financial Viability Document 4/2016 Financial Viability
Family Day Care Home Sponsors
Applications, forms and resources for sponsors of family day care homes DCH Web Resources
Locate a sponsor – find out which home sponsors serve your county DCH Locator
Food & Nutrition
Number Name/Description Format
Crediting Handbook for CACFP (Effective July 1, 2014) – does not include infants 04/2014 Crediting Handbook for CACFP
NS-408-G Crediting Foods in the Child and Adult Care Food Program (Nebraska) – does include infants 04/2008 Crediting Handbook for CACFP_infants
Grains Chart Format
Grain Chart 08/2017 Grain Chart
NEW! Sample Menus Format
1 & 2 year olds 08/2017 1 & 2 Year Old Sample Menu
3 – 5 year olds 08/2017 3 – 5 Year Old Sample Menu
6 – 12 year olds & 13 – 18 year olds 08/2017 6 – 12 & 13- 18 Year Old Sample Menu
Adults 08/2017 Adult Sample Menu
Food Charts
Meal pattern for children, ages 1 – 12  06/2017 Child Meal Pattern
Meal pattern for adults   06/2017 Adult Meal Pattern
Meal pattern for infants (birth up to first birthday)   06/2017 Infant Meal Pattern
Approved Milk Substitutes
Updated list of milk substitutes approved for use in CACFP  06/2017 Milk Substitutes
What’s Cookin’ II cookbook for family day care homes
What’s Cookin’ II – recipes Recipes_pdf
Farm to Preschool Network
Seasonal Crop Tunnel Systems (clickable link) Seasonal Crop Tunnel Systems PDF
Buying Local Guide (clickable link) Buying Local Guide PDF
Farm to Preschool Network (clickable link) Farm to Preschool Network
Menu Production Records
Select the version that best meets the needs of your center.
Child and Adult Care Centers
NS-501-A Daily Production Record – This version allows for menu, foods used and quantity prepared for breakfast, morning snack, lunch, afternoon snack, supper and evening snack 03/2017 Daily Production Record Ver. A
NS-501-B Daily Production Record – This version allows for the menu, foods used, and total quantity prepared for breakfast, morning snack, lunch and afternoon snack 03/2017 Daily Production Record Ver. B
Cycle menu planner – requires 8 1/2″ x 14″ paper to print 01/2005 Cycle Menu Planner_Word
Cycle Menu Planner_PDF
Feeding Infants
Obligation to offer infant meals 05/2002 Infant Meal Offer Obligation
Infant Meal Pattern 06/2017 Infant Meal Pattern
NEW! Infant Feeding Records 03/2019 Infant Feeding Records
Developmental Readiness Form 06/2018 Infant Formula Selection & Solid Foods
NEW! SPANISH Developmental Readiness Form 06/2019 Infant Formula Selection Solid Foods_Spanish
Feeding Infants – A Guide for Use in the Child Nutrition Programs (USDA Publication FNS-258) Feeding Infants in CNP
Additional resources on feeding infants Infant Feeding Resources
Breastfeeding Resources
What’s in Breastmilk 10/2016
Breastfeeding Facts 4/2015
Medical Statement Form
Medical Statement 4/2018 Use for medical conditions requiring meal substitute.
Req Meal Accommodation 4/2018 Use for creditable meals substitutes based on personal preference
Managing Food Allergies
CDC Toolkit (clickable link) 5/2015 CDC Toolkit_web version
Infant Production Records
You may select the set that works best in your child care center.
Set One: NS-502-A Weekly Infant Meal Records – Five days of meals may be recorded for an individual infant. 12/2011 Infant Meal Records Ver. A
Set Two: NS-502-B Daily Infant Meal Records – Meals served to several infants may be recorded for a full day. 12/2011 Infant Meal Records Ver. B
Training Resources
NEW! Infant FY2017 New Meal Pattern Training PPT 06/2017 Infant 2017 Meal Pattern Training
NEW! FY2017 New Meal Pattern 06/2017 2017 Meal Pattern Training
Introduction to the CACFP – training manual for adult care centers 08/2015 Adult Care Centers Training Manual
CACFP Training Log – this may be used to document your CACFP staff training 04/2007 CACFP Training Log
Civil Rights Training 2/2015 Civil Rights Training
USDA Resources
  USDA Food Buying Guide   USDA Food Buying Guide_pdf
Child Care Recipes from USDA Child Care Recipes from USDA_pdf
Nibbles for Health – from USDA Nibbles for Health_pdf
USDA Regulation & Policy
  Code of Federal Regulations 01/2011 Code of Federal Regulations
USDA FNS CACFP Program Policy Memos 08/2014 USDA Program Policy Memos
USDA Food & Nutrition Services Instructions USDA Food & Nutrition Services Instructions
Questions and Answers – consolidated Q & A’s from the U.S. Department of Agriculture Mountain Plains Regional Office USDA FAQ
WIC Resources
  WIC Brochure (English) – 2 pages   English WIC Brochure_pdf
WIC Brochure (Spanish) – 2 pages Spanish WIC Brochure_pdf

You may download files by right-clicking your mouse and selecting “Save Target As…”

The following forms are for Fiscal Year 2020.

NS-402-G
Income Eligibility Guidelines for FY 2020 – guidelines effective July 1, 2019 – June 30, 2020.
NS-402-G-Income-Guidelines-2019

NS-100-C
Income Eligibility Form – Child Care Centers – FY 2020       6/2019
NS-100C – Child Income Eligibility and Enrollment Form FY20 Final

NS-105-C
Child Enrollment Form – sample children must be enrolled in CACFP annually
NS-105-C pdf

NS-106-C
Child Enrollment Form – instructions for centers
NS-106-C pdf

Updated August 7, 2019 4:35pm