Adult Day Care Centers
(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
- Account Request for HCS (DOH-5039) (PDF, 34KB, 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.)
- Application for Participation of Individual Centers (DOH-3682) PDF FILL-IN FORMAT (PDF, 97KB, 4pg.)
- Authorization for Online Health Commerce System (HCS) Account Creation (CACFP-179) (PDF, 33.8KB, 1pg.)
- Board of Directors (CACFP-4217) PDF FILL-IN FORMAT (PDF, 270KB, 2pg.)
- Certificate of Authority (CACFP-3671C) PDF FILL-IN FORMAT (PDF, 40KB, 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.)
- Daily Meal Count Form for Day Care Centers (CACFP-116) (PDF, 37KB, 1pg.)
- Daily Meal Count Form for Day Care Centers - Snack and Suppers (CACFP-128) (PDF, 37KB, 1pg.)
- Food Production Record Instructions (CACFP-3696A) (PDF, 83KB, 5pg.)
- Food Production Record (CACFP-3696B) PDF FILL-IN FORMAT (PDF, 40KB, 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.)
- Spanish Version (DOH-3834es) (PDF, 55KB, 2pg.)
- Russian Version (DOH-3834ru) (PDF, 375KB, 2pg.)
- Chinese Version (DOH-3834zh) (PDF, 206KB, 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 (CACFP-3673zh) (PDF, 245KB, 1pg.)
- Monitoring Checklist for Day Care Centers (CACFP-4259) PDF FILL-IN FORMAT Checklist used by sponsoring organizations to document required monitoring of centers.(PDF, 58.4KB, 1pg.)
- Outside Employment Policy - Sample
- Order Form for Sponsoring Organizations of Day Care Centers (CACFP-3718) (PDF, 380KB, 2pg.)
- Participant Data Form (CACFP-3854C) To annually collect racial-ethnic information of the children in care.(PDF, 105KB, 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.)
- Vended Meals: Vendor Contract Packet - When vended meal purchases will be $100,000 or less (CACFP-142) (PDF, 277KB, 8pg.)
- Vended Meals: Extension of Vendor Contract to Provide Meals and/or Snacks (CACFP-141) (PDF, 47KB, 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, 902KB, 60pg.)
- 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.)
