Child and Adult Care Food Program (CACFP) Provider Application Change Form

* required field

Complete only the applicable fields on this document to make changes to an existing approved application. If the provider is moving, changing approval types, requesting a name change or transferring, a full application is required with all required supporting documents. 

Sponsor Representative Organizational Details and Contact Information
Sponsor Representative Contact Informaiton
Provider Information
Section 1 – Provider Details
Please identify any changes being made to the initial application for any of the sections below.
Provider Details
Backup Provider Details
Please complete this section if you need to add any new backup provider, update a backup provider's FPC Expiration Date or remove a backup provider. Note: For all new backup providers, please upload fingerprint card (FPC) or application.
I need to make updates to a second Backup Provider
Section 2 - Provider Application Changes
Check the day of the week where Hours of Care have been changed (the start time or the end time).
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Check all that apply:
Providers Own Children
Section 3 – Meal Service
1st Shift
Breakfast
AM Snack
Lunch
PM Snack
Supper
Evening Snack
2nd Shift
Breakfast
AM Snack
Lunch
PM Snack
Supper
Evening Snack
Attestation
I, the Sponsor Representative, hereby certify any of the above changes made to the initial application have been communicated by the provider to the sponsoring agency and have been approved effective on this date.