MONTH__________________________________________________________ PROVIDERS NAME_______________________________________________

Meal Count and Attendance Form

Section I: This record must be kept after each meal service by the provider. The provider must have an enrollment form for each child. Meal Codes: B= Breakfast A= AM Snack L= Lunch P= PM Snack S= Supper D 1. Name 2. Name 3. Name 4. Name 5. Name 6. Name 7. Name
A T E

8. Name

9. Name

10. Name

T O T A L

D A T E

B 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
T o t a l

S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Section II: Complete Monthly and submit to Sponsor. Children being served Last Name First Name 1 2 3 4 5 6 7 8 9 10 (X) If providers Children

Age

Monthly Total Served Each Child B A L P

I certify that I have followed the USDA meal pattern guidelines and am claiming no more than two meals and one snack or two snacks and one meal (not to exceed a total of three) per child per day served to enrolled children. Providers Signature: Date: Section III: FOR SPONSOR USE ONLY Monthly Totals Payments to Provider Number Rate Amount $ Total Earned $ Deductions $ Balance Due Provider

Meal Breakfast Lunch Snacks Supper

Total Meals Claimed

ADA:

Check #:

Initials: