Adult Day Care Centers

• Forms
• Informational Charts and Guides

(All Brochures, Forms, Informational Charts, and Sample Menus 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, print or save fill-in PDF documents, the latest Adobe Acrobat Reader must be installed on your computer.

Forms

• Agreement Between the State and Sponsoring Organizations of Day Care Centers (DOH-3840) (PDF)
• Annual Update of CACFP Manual for Sponsors of Day Care Centers (CACFP-3979C) (PDF)
• Application for Participation of Individual Centers (DOH-3682) (PDF)
• Authorization for Online Health Commerce System (HCS) Account Creation (DOH-5158) (PDF)
• Board of Directors (DOH-5165) Formerly CACFP-4217 (PDF)
• Certificate of Authority (DOH-5168C) Formerly CACFP-3671C (PDF)
• Claim for Reimbursement for Sponsors of Day Care Centers (DOH-3703) PDF FILL-IN FORMAT - To submit monthly data for payment. (PDF)
• Daily Meal Count Record (CACFP-116) (PDF)
• Daily Meal Count Form for Day Care Centers - Snack and Suppers (CACFP-128) (PDF)
• Food Production Record Instructions (CACFP-3696A) (PDF)
• Food Production Record - Breakfast, Snack, Lunch (CACFP-3696B) PDF FILL-IN FORMAT (PDF)
• Food Production Record - Lunch, Snack, Supper (CACFP-3696C) PDF FILL-IN FORMAT (PDF)
• Income Eligibility Application for Adult Day Care Centers (DOH-3834) To determine eligibility for free or reduced priced meals for adults in care.(PDF)
  • Spanish Version (DOH-3834es) (PDF)
  • Russian Version (DOH-3834ru) (PDF)
  • Chinese Version (DOH-3834zh) (PDF)
• Letter to Households (CACFP-3673) Mandatory annual letter explaining the income eligibility applications and participant rights. (PDF)
  • Spanish Version (CACFP-3673es) (PDF)
  • Russian Version (CACFP-3673ru) (PDF)
  • Chinese Version (CACFP-3673zh) (PDF)
  • Arabic Version (CACFP-3673ar) (PDF)
• Monitoring Checklist for Day Care Centers (CACFP-4259) Checklist used by sponsoring organizations to document required monitoring of centers.(PDF)
• Outside Employment Policy - Sample (CACFP-187) (PDF)
• Order Form for Sponsoring Organizations of Day Care Centers (CACFP-3718) (PDF)
• Participant Data Form (CACFP-3854C) To annually collect racial-ethnic information of the children in care. (PDF)
• Reimbursement Rates For Day Care Centers (CACFP-124C) (PDF)
• Substitute Form W-9
  NYS Office of the State Comptroller Substitute Form W-9 Request for Taxpayer Identification Number and Certification.
• Vendor Contracts
• Extension of Vendor Contract to Provide Meals and/or Snacks (CACFP-141) (PDF)
• Invitation for Bid and Vendor Contract Packet (CACFP-143)-When vended meal purchases will be more than $100,000 (PDF)
• Vendor Contract Packet (CACFP-142) -When vended meal purchases will be $100,000 or less (PDF)

Informational Charts and Guides

• 2010 Census Data for New York State (PDF)
• Adult Meal Pattern (Publication No. 1258) Chart indicating required components and minimum quantities of food for adults in care. (PDF)
  • Arabic Version (PDF)
  • Chinese Version (PDF)
  • Haitian-Creole Version (PDF)
  • Korean Version (PDF)
  • Russian Version (PDF)
  • Spanish Version (PDF)
• Claim Submission Deadline (PDF)
• Crediting Foods in CACFP (PDF)
  • Chinese Version (PDF)
  • Haitian-Creole Version (PDF)
  • Italian Version (PDF)
  • Korean Version (PDF)
  • Russian Version (PDF)
  • Spanish Version (PDF)
• 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)

Sample Menus

• Sample Child and Adult Care Menus (CACFP-182) (PDF)