Special Assistance Provision 2/3 Base Year Application

* required field

Please review the USDA Special Assistance Provision Manual and Online Course: How to Apply and Operate Special Assistance Provision 2/3 Base Year. Once completed, submit the application and required documents for review. Please note that this application is not approved until you receive an official letter of approval from this department. This application is due no later than June 30th annually.

LEA Information

Local Educational Agency (LEA) Name: *

CTDS# *

School Food Authority (SFA) Contact/Title: *

SFA Email Address *

Phone#: *

Special Assistance Provision Participation

Indicate the Special Assistance Provision that will be operated (e.g. Provision 2 or 3): *

Indicate the number of applying sites that will be participating in a base year: *

Applying sites (as shown in CNPWeb)

List the legal name of applying sites (as shown in CNPWeb)

Site 1 *

Site 1 Base Year *

Site 1 Meal Participation *

Select site's meal participation

Do you need to list a second site?

Second Site

Site 2 *

Site 2 Base Year *

Site 2 Meal Participation *

Select site's meal participation

Do you need to list a third site?

Third Site

Site 3 *

Site 3 Base Year *

Site 3 Meal Participation *

Select site's meal participation

Do you need to list a fourth site?

Fourth Site

Site 4 *

Site 4 Base Year *

Site 4 Meal Participation *

Select site's meal participation

Applying sites (as shown in CNPWeb) File Upload

List the legal name of applying sites (as shown in CNPWeb)

Attached the list of all sites by attaching file using the fields shown: *

Please list site name(s) below, or indicate that a list of all sites is attached (if applying for more than four sites). The list needs to indicate the fields shown below on School District Letterhead.

Legal name of applying sites (as shown in CNPWeb)
Base Year
Participation in BREAKFAST (B), LUNCH(L),OR BOTH (BL)

Required Documents:

Open each file (Application, Addendum, and Training), complete, save, and upload the files within this form by clicking 'Choose File' under the appropriate field below.

Special Assistance Application
Addendum- Provision 2
Addendum- Provision 3
Training Certificate: How to Apply and Operate Special Assistance Provision 2/3 Base Year

Special Assistance Application *

Addendum *

Training Certificate *

I CERTIFY

I CERTIFY that the information in this application is true, and that I agree to carry out the terms of the agreement to operate the Special Assistance Program. I understand that this information is given in connection with the receipt of federal funds and that deliberate misinterpretation may be subject to prosecution under applicable federal statutes.

Name (authorized signatory): *

Date: *

Month

Day

Year

Leave this field blank