Adult Day Care Centers
All Forms, and Informational Charts are available below in PDF Format or may be requested by contacting the Child and Adult Care Food Program at our Toll Free Number: 1-800-942-3858. To view or print PDF Documents, Adobe Acrobat Reader must be installed on your computer.
Forms
- Agreement Between the State and Sponsoring Organizations of Day Care Centers (DOH-3840) (PDF, 88.2KB, 2pg.)
- Application for Participation of Adult Day Care Centers (DOH-3868) (PDF, 67KB, 2pg.)
- Download Application for Participation of Adult Day Care Centers (DOH-3868) (RTF, 1.41MB, 2pg.)
- Certificate of Authority (DOH-3671) (PDF, 58.2KB, 1pg.)
- Download Certificate of Authority (DOH-3671) (RTF, 677KB, 1pg.)
- Claim for Reimbursement for Sponsoring Organizations of Day Care Centers with Instructions (DOH-3703) To submit monthly data for payment.(PDF, 194KB, 2pg.)
- Download Claim for Reimbursement (DOH-3703) (RTF, 777KB, 2pg.)
- Daily Meal Count Form for Day Care Centers (PDF, 120KB, 1pg.)
- Download Daily Meal Count Form for Day Care Centers (RTF, 667KB, 1pg.)
- Food Production Record Instructions (CACFP-3696A) (PDF, 84.8KB, 4pg.)
- Food Production Record (CACFP-3696B) (PDF, 29.5KB, 1pg.)
- Download Food Production Record (CACFP-3696B) (RTF, 653KB, 1pg.)
- Income Eligibility Application for Adult Day Care Centers (DOH-3834) To determine eligibility for free or reduced priced meals for adults in care.(PDF, 193KB, 2pg.)
- Download Income Eligibility Application (DOH-3834) (RTF, 99KB, 2pg.)
- Versión en español (DOH-3834es) (PDF, 55KB, 2pg.)
- Descargar (DOH-3834es) (RTF, 99KB, 2pg.)
- Russian Version (DOH-3834ru) (PDF, 170KB, 2pg.)
- Download Russian Version (DOH-3834ru) (RTF, 111KB, 2pg.)
- Chinese Version (DOH-3834zh) (PDF, 206KB, 2pg.)
- Download Chinese Version (DOH-3834zh) (RTF, 103KB, 2pg.)
- Letter to Households (CACFP-3673) Mandatory annual letter explaining the income eligibility applications and participant rights. (PDF, 64.1KB, 1pg.)
- Download CACFP-3673 (RTF, 658KB, 1pg.)
- Versión en español (CACFP-3673es) (PDF, 67.3KB, 1pg.)
- Descargar CACFP-3673es (RTF, 657KB, 1pg.)
- Management Plan for Renewing Independent Centers (CACFP-144) (PDF, 41.7KB, 2pg.)
- Download Independent Center Management Plan (CACFP-144) (RTF, 700KB, 2pg.)
- Management Plan for Renewing Sponsoring Organizations (CACFP-145) (PDF, 43.3KB, 2pg.)
- Download Sponsor Mangement Plan (CACFP-145) (RTF, 705KB, 2pg.)
- Monitoring Checklist for Day Care Centers (CACFP-4259) Checklist used by sponsoring organizations to document required monitoring of centers.(PDF, 58.4KB, 1pg.)
- Download Monitoring Checklist (CACFP-4259) (RTF, 676KB, 1pg.)
- Outside Employment Policy - Sample
- Download Outside Employment Policy - Sample (RTF, 12.7KB, 1pg.)
- Order Form for Sponsoring Organizations of Day Care Centers (CACFP-3718) (PDF, 66KB, 2pg.)
- Download Order Form (CACFP-3718) (RTF, 759KB, 2pg.)
- Participant Data Form (CACFP-3854C) To annually collect racial-ethnic information of the children in care.(PDF, 105KB, 1pg.)
- Download Participant Data Form (CACFP-3854C) (RTF, 643KB, 1pg.)
- Sponsor Budget Plan of CACFP Reimbursements and Expenses (CACFP-4298) (PDF, 98.1KB, 2pg.)
- Download CACFP-4298 (RTF, 785KB, 2pg.)
- Vended Meal Program: Bid Packet Policy Information (Policy Memo Number 110) for CACFP-118 and CACFP-141 Forms Listed Below
- Vended Meal Program: Invitation for Bid and Vendor Contract to Provide Meals and/or Snacks (CACFP-118) (PDF, 139KB, 6pg.)
- Instructions for Completing the Bid Process (CACFP-118i) (PDF, 26.4KB, 2pg.)
- Download CACFP-118 (RTF, 1.4MB, 6pg.)
- Vendor Contract to Provide Meals and/or Snacks (CACFP-119) (PDF, 146KB, 5pg.)
- Download CACFP-119 (RTF, 800KB, 5pg.)
- Vendor Contract Extension to Provide Meals/Snacks (CACFP-141) (PDF, 34KB, 1pg.)
- Download CACFP-141 (RTF, 672KB, 1pg.)
Informational Charts and Guides
- 60/90 Day Claims Submission Calendar (PDF, 42KB, 2pg.)
- 2000 Census Data for New York State
- Adult Meal Pattern (CACFP-101) Chart indicating required components and minimum quantities of food for adults in care. (PDF, 46.0KB, 1pg.)
- Versión en español (PDF, 47.5KB, 1pg.)
- Crediting Foods in CACFP (PDF, 678KB, 29pg.)
- Income Guidelines for Day Care Centers (CACFP-3687) Chart indicating income criteria to qualify for free or reduced price meals reimbursement. For Sponsoring Organization Use Only. (PDF, 170KB, 1pg.)
- Download CACFP-3687 (RTF, 692KB, 1pg.)