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
- Account Request for HCS (DOH-5039) (PDF, 34KB, 1pg.)
- Download Account Request for HCS (DOH-5039) (RTF, 1.27MB, 1pg.)
- Agreement Between the State and Sponsoring Organizations of Day Care Centers (DOH-3840) (PDF, 584KB, 2pg.)
- Annual Update of CACFP Manual for Sponsors of Day Care Centers (CACFP-3979C) (PDF, 339KB, 2pg.)
- Download CACFP-3979C (RTF, 746KB, 2pg.)
- Application for Participation of Individual Centers (DOH-3682) (PDF, 97KB, 4pg.)
- Download Application for Participation of Individual Centers (DOH-3682) (RTF, 1.93MB, 4pg.)
- Authorization for Online Health Commerce System (HCS) Account Creation (CACFP-179) (PDF, 33.8KB, 1pg.)
- Download Authorization (CACFP-179) (RTF, 1.27MB, 1pg.)
- Board of Directors (CACFP-4217) PDF FILL-IN FORMAT (PDF, 270KB, 2pg.)
- Download Board of Directors (CACFP-4217) (RTF, 801KB, 2pg.)
- Certificate of Authority (CACFP-3671C) PDF FILL-IN FORMAT (PDF, 40KB, 1pg.)
- Download Certificate of Authority (CACFP-3671C) (RTF, 1.27MB, 1pg.)
- Claim for Reimbursement for Sponsors of Day Care Centers (DOH-3703) PDF FILL-IN FORMAT - To submit monthly data for payment. (PDF, 249KB, 2pg.)
- Download Claim for Reimbursement (DOH-3703) (RTF, 3.38MB, 2pg.)
- Daily Meal Count Form for Day Care Centers (PDF, 37KB, 1pg.)
- Download Daily Meal Count Form for Day Care Centers (RTF, 1.29MB, 1pg.)
- Daily Meal Count Form for Day Care Centers - Snack and Suppers (PDF, 37KB, 1pg.)
- Download Daily Meal Count Form for Day Care Centers - Snack and Suppers (RTF, 1.28MB, 1pg.)
- Food Production Record Instructions (CACFP-3696A) (PDF, 83KB, 5pg.)
- Food Production Record (CACFP-3696B) PDF FILL-IN FORMAT (PDF, 40KB, 1pg.)
- Download Food Production Record (CACFP-3696B) (RTF, 1.27MB, 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, 65KB, 2pg.)
- Download Income Eligibility Application (DOH-3834) (RTF, 1.35M, 2pg.)
- Spanish Version (DOH-3834es) (PDF, 55KB, 2pg.)
- Download Spanish Version (DOH-3834es) (RTF, 99KB, 2pg.)
- Russian Version (DOH-3834ru) (PDF, 375KB, 2pg.)
- Download Russian Version (DOH-3834ru) (RTF, 800KB, 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, 57KB, 1pg.)
- Spanish (CACFP-3673es) (PDF, 134KB, 1pg.)
- Russian Version (CACFP-3673ru) (PDF, 321KB, 1pg.)
- Chinese Version (DOH-3673zh) (PDF, 245KB, 1pg.)
- 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, 380KB, 2pg.)
- Download Order Form (CACFP-3718) (RTF, 894KB, 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.)
- Reimbursement Rates For Day Care Centers (CACFP-124C) (PDF, 36KB, 1pg.)
- Vended Meals: Invitation for Bid and Vendor Contract Packet - When vended meal purchases will be more than $100,000 (CACFP-143) (PDF, 289KB, 10pg.)
- Download CACFP-143 (RTF, 3.95MB, 10pg.)
- Vended Meals: Vendor Contract Packet - When vended meal purchases will be $100,000 or less (CACFP-142) (PDF, 277KB, 8pg.)
- Download CACFP-142 (RTF, 3.90MB, 8pg.)
- Vended Meals: Extension of Vendor Contract to Provide Meals and/or Snacks (CACFP-141) (PDF, 47KB, 2pg.)
- Download CACFP-141 (RTF, 1.33MB, 2pg.)
Informational Charts and Guides
- 60/90 Day Claims Submission Calendar (PDF, 42KB, 2pg.)
- 2010 Census Data for New York State (PDF, 64KB, 2pg.)
- Crediting Foods in CACFP (PDF, 1.96MB, 56pg.)
- Healthy Adult Meal Pattern (CACFP-101) Chart indicating required components and minimum quantities of food for adults in care. (PDF, 222KB, 1pg.)
- Arabic Version (PDF, 582KB, 1pg.)
- Chinese Version (PDF, 392KB, 1pg.)
- Haitian-Creole Version (PDF, 220KB, 1pg.)
- Korean Version (PDF, 306KB, 1pg.)
- Russian Version (PDF, 509KB, 1pg.)
- Spanish Version (PDF, 219KB, 1pg.)
- 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, 55KB, 1pg.)
