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 2019.
NS-402-G Income Eligibility Guidelines for FY 2019 – guidelines effective July 1, 2018 – June 30, 2019. 6/2018 NS-402-G Income Guidelines 2019
NS-100-C Income Eligibility Form – Child Care Centers – FY 2019 6/2018 NS-100C – Child Income Eligibility and Enrollment Form FY19 Final
NS-100-C Spanish Spanish Income Eligibility Form – Child Care Centers – FY 2019 NS-100C – Child Income Eligiblity and Enrollment Form ES-US
NS-101-C Income Eligibility Form – Instructions – Child Care Centers 6/2018 NS-101-C FY19 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. 6/2018 NS-100-C-a Additional Children FY 19
NS-200-C Income Eligibility Form – Adult Care Centers – FY 2019 6/2018 NS-200A – Adult Income Eligibility Enrollment FY19
NS-201-A Income Eligibility Form – Instructions – Adult Care Centers 4/2016 Adobe pdf
NS-202-A Cover Letter to Households – Adult Care Centers – FY 2019 4/2016 Coming Soon
NS-204-A Instructions to Households – Adult Care Centers – FY 2019 4/2016 Coming Soon
Alternate Translations of USDA Income Eligibility Form 4/5/2017 Web
Spanish translation – Income Eligibility Form 5/2011 Adobe pdf
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 Adobe pdf
NS-106-C Child Enrollment Form – instructions to centers 4/2015 Adobe pdf
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 Adobe pdf

11″ x 27″

NS-401-G Monthly Claim for Reimbursement Worksheet 04/2009 Adobe pdf
Microsoft Word
Microsoft Excel
NDE 28-017 Claim for Reimbursement – Child Care Centers 01/2011 Adobe pdf
NDE 28-018 Claim for Reimbursement – Adult Care Centers 04/2009 Adobe pdf
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 Adobe pdf
W-9/ACH IRS W-9 and enrollment for direct deposit of claim reimbursement 04/2014 Adobe pdf
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 Web
Adobe pdf
What to Expect – Getting ready for a compliance review or audit 07/2006 Adobe pdf
Signature Pages
NDE 01-017
Page 7
Certificate of Authority (change in responsible individuals/principals) 06/2018 NDE01-017-Cert-of-Authority FY19 final
NDE 01-017
Page 8
Organization Representatives Signature Page 06/2018 NDE01-017-Organization-Statement FY19-final
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 06/2018 FSMC Contract Packet complete- final
Sample Delivery Ticket Adobe pdf
Small Purchase Procurement (done annually) 05/2014 Adobe pdf
Approved vendor list found here 06/2017
Federal Regulations Adobe pdf
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 Adobe pdf
NS-406-G Sample Site Review form – for sponsors of multiple sites 04/2018 Coming Soon
NS-409-G Administrative Review procedures – steps for submitting an administrative review (appeal) regarding NDE actions 06/2017 Adobe pdf
Nebraska Household Contact System (for sponsors of more than one site) 04/2005 Adobe pdf
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 Microsoft Word
 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? Current contents may be downloaded here 12/2011 Web
CACFP Handbook for Sponsors of Multiple Sites 11/2008 Adobe pdf
Financial Viability Document 4/2016 Adobe pdf
Family Day Care Home Sponsors
Applications, forms and resources for sponsors of family day care homes Web
Locate a sponsor – find out which home sponsors serve your county Web
Food & Nutrition
Number Name/Description Format
NEW! Crediting Handbook for CACFP (Effective July 1, 2014) – does not include infants 04/2014 Adobe pdf
NS-408-G Crediting Foods in the Child and Adult Care Food Program (Nebraska) – does include infants 04/2008 Adobe pdf
Grains Chart Format
NEW! Grain Chart 08/2017 Adobe pdf
NEW! Sample Menus Format
1 & 2 year olds 08/2017 Adobe pdf
3 – 5 year olds 08/2017 Adobe pdf
6 – 12 year olds & 13 – 18 year olds 08/2017 Adobe pdf
Adults 08/2017 Adobe pdf
Food Charts
NEW! Meal pattern for children, ages 1 – 12  06/2017 Web
NEW! Meal pattern for adults   06/2017 Web
NEW! Meal pattern for infants (birth up to first birthday)   06/2017 Web
Approved Milk Substitutes
Updated list of milk substitutes approved for use in CACFP  06/2017 Adobe pdf
What’s Cookin’ II cookbook for family day care homes
What’s Cookin’ II – recipes Link to Adobe pdf files
Farm to Preschool Network
Seasonal Crop Tunnel Systems (clickable link) Adobe pdf
Buying Local Guide (clickable link) Adobe pdf
Farm to Preschool Network (clickable link) Web
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 Adobe pdf
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 Adobe pdf
Cycle menu planner – requires 8 1/2″ x 14″ paper to print 01/2005 Microsoft Word
Adobe PDF
Feeding Infants
Obligation to offer infant meals 05/2002 Adobe pdf
NEW! Infant meal pattern 06/2017 Adobe pdf
Infant Feeding Record 0-5 months 06/2018 UPDATED Infant (0-5 Months ) -Meal Production Records Final 4.2018
Infant Feeding Record 6-11 months 06/2018 UPDATED Infant (6-12 month) – Meal Production Records 4.2018
Developmental Readiness Form 06/2018 Infant Formula Selection & Solid Foods
Feeding Infants – A Guide for Use in the Child Nutrition Programs (USDA Publication FNS-258) Adobe pdf
Additional resources on feeding infants Web
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 Web
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 Adobe pdf
Set Two: NS-502-B Daily Infant Meal Records – Meals served to several infants may be recorded for a full day. 12/2011 Adobe pdf
Training Resources
NEW! Infant FY2017 New Meal Pattern Training PPT 06/2017 Adobe pdf
NEW! FY2017 New Meal Pattern 06/2017 Adobe pdf
Introduction to the CACFP – training manual for adult care centers 08/2015 Adobe pdf
CACFP Training Log – this may be used to document your CACFP staff training 04/2007 Adobe pdf
Civil Rights Training 2/2015 Adobe pdf
USDA Resources
  USDA Food Buying Guide   Link to Adobe pdf files
Child Care Recipes from USDA Link to Adobe pdf files
Nibbles for Health – from USDA Link to Adobe pdf files
USDA Regulation & Policy
  Federal Regulations 01/01/2011 Web
USDA FNS CACFP Program Policy 08/2014 Web
USDA Food & Nutrition Services Instructions Web
USDA Policy Memos – from the Mountain Plains Region of USDA Web
Questions and Answers – consolidated Q & A’s from the U.S. Department of Agriculture Mountain Plains Regional Office Web
WIC Resources
  WIC Brochure (English) – 2 pages   pdf
WIC Brochure (Spanish) – 2 pages pdf