PI-9550-IG Advanced Placement Expansion Reimbursement Request

Wisconsin Department of Public Instruction INSTRUCTIONS: Complete and return two (2) copies to: PERMANENT AGREEMENT—POLICY STATEMENT WISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION SPECIAL MILK PROGRAM—NONSCHOOL PROGRAMS ATTN: AMANDA KANE PI-1480-AP (Rev. 02-16) COMMUNITY NUTRITION PROGRAMS PO BOX 7841 MADISON, WI 53707-7841 Agency Code An approved copy will be returned for your files.

I. GENERAL INFORMATION Name of Sponsoring Agency Mailing Address Street, City, State, ZIP

Contact Person Title Phone Area Code/No.

E-Mail Address Print Carefully

II. AGREEMENT

In order to effectuate the purpose of the Special Milk Program (7 CFR, activities), be excluded from participation in, be denied benefits of, or Part 215 and 245), the Department of Public Instruction hereinafter otherwise be subject to discrimination under any program or activity referred to as the DEPARTMENT, and the Sponsoring Agency applicant, for which the program applicant receives federal financial assistance hereinafter referred to as the SPONSORING AGENCY, agree as follows: from FNS; and hereby gives assurance that it will immediately take measures necessary to effectuate this agreement. THE DEPARTMENT AGREES THAT IT WILL: By accepting this assurance, the sponsoring agency agrees to compile 1. Reimburse the Sponsoring Agency, to the extent of funds available, data, maintain records, and submit reports, as required, to permit for milk served to children under terms of this contract, at the assigned effective enforcement of the nondiscrimination laws and permit rates of reimbursement during the fiscal year of which the contract is authorized USDA personnel during normal working hours to review in effect. such records, books and accounts as needed to ascertain compliance 2. Notify the Sponsoring Agency in writing of any change in assigned with the nondiscrimination laws. If there are any violations of this rates of reimbursement. assurance, the Department of Agriculture, Food and Nutrition Service, shall have the right to seek judicial enforcement of this assurance. This THE SPONSORING AGENCY AGREES THAT IT WILL: assurance is binding on the program applicant and its successors, 1. Operate a nonprofit milk service. A nonprofit milk service means a milk transferees and assignees, as long as they receive assistance or service maintained by or on behalf of the participating site(s) for the retain possession of any assistance from the Department. The person benefit of the children, all income from which is used solely for the or persons whose signatures appear below are authorized to sign this operation or improvement of such milk service. assurance on behalf of the program applicant. 2. Claim reimbursement only for fluid milk, flavored or unflavored, which THE DEPARTMENT AND THE SPONSORING AGENCY MUTUALLY meets the definition of milk and is served to eligible children. AGREE THAT: 3. Milk served to adults is not eligible for reimbursement. 1. Schedule A that lists the participating sites shall be part of this 4. Submit monthly claims for reimbursement in accordance with proce- Application-Agreement. dures established by the Department. 2. The terms of this agreement shall not be modified or changed in any 5. Maintain full and accurate records of its milk program, including, but way other than with consent in writing of both parties. not limited to program income and expenditures, the total number of 3. Participating sites may be added or deleted from Schedule A as need half-pints of milk purchased, the number of half-pints served to arises and the references to Schedule A shall be deemed to include children and to adults, and maintain such records for a period of 3 such schedules as supplemented and amended. years after the fiscal year to which they pertain. 4. No member of or delegate to Congress, or Resident Commissioner 6. Upon request, make all records pertaining to the milk program shall be admitted to any share or part of this agreement or to any available to the Department, the U.S. Department of Agriculture, and benefits that may arise there from; but this provision shall not be the Office of Audit for audit and administrative review, at a reasonable construed to extend to this agreement if made with a corporation for its time and place. general benefit. 7. Provide adequate storage and proper refrigeration for all milk within a 5. For the purpose of this agreement the following terms shall be temperature range of 35 to 40 degrees F. construed to mean respectively: 8. Comply with Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d a. Adults: Means those persons not included under the definition of et seq.), Title IX of the Education Amendments of 1972 (20 U.S.C. children. 1781 et seq.), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. b. Child Care Institution: Any nonprofit nursery school (other than 794), the Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.); all nursery schools falling within the definition of school), child care provisions required by the implementing regulations of the Department center, settlement house, summer camp, service institution of Agriculture; Department of Justice Enforcement Guidelines, 28 CFR participating in the Summer Food Service Program or the Child and 50.3 and 42; and FNS directives and guidelines, to the effect that, no Adult Care Food Program, or similar nonprofit institution devoted to person shall, on the basis of race, color, national origin, age, disability, the care and training of children. "Child Care Institution" as used in sex, gender identity, religion, reprisal, and, where applicable, political this part includes, where applicable, the authorized sponsoring beliefs, marital status, familial or parental status, sexual orientation, or agency which has entered into an agreement under the Program all or part of an individual’s income is derived from any public assis- for a child care institution. tance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department, (Not c. Children: Means persons under 19 chronological years of age in all prohibited bases will apply to all programs and/or employment child care institutions; or persons under 21 chronological years of Page 2 PI-1480-AP age attending schools; or students, including students who are h. Needy Children: Children who attend child care institutions mentally or physically handicapped, of high school grade or under participating in the Program and who meet the eligibility standards as determined by the state and who are participating in a school for free milk approved by the Department. program established for the mentally or physically disabled, or high i. Nonprofit Milk Service: Milk service maintained by or on behalf of school grade or under as determined by the state educational the participating site for the benefit of the children, all income from agency. which is used solely for the operation or improvement of such food d. Cost of Milk: The net purchase price paid by the child care or milk services. institution to the milk supplier for milk delivered to the child care j. Nonprofit Summer Camp for Children: Means nonprofit camps in institution. This does not include any amount paid to the milk which, during May through September, nonprofit feeding services supplier for serving, rental or installment purchase of milk service are for children of high school grade and under or if not applicable, equipment. 18 years of age and under, and which do not participate in the e. Food Authority: The governing body responsible for the administra- Summer Food Service Program for Children. tion of one or more child care institutions participating in the k. Out-Side-School-Hours Care Center: A public or private nonprofit Program and which has the legal authority to operate a nonprofit organization approved to provide organized nonresidential child food or milk service. care services to enrolled children outside of school hours. f. Homeless Feeding Site: A feeding site whose primary purpose is to This agreement may be terminated upon 10 days written notice on the provide shelter and one or more regularly scheduled meal services part of either party and the Department may terminate this agreement per day to homeless families and which is not a residential child immediately after receipt of evidence that the terms and conditions of this care institution. agreement have not been fully complied with by the Sponsoring Agency g. Milk: Pasteurized fluid types of unflavored or flavored whole milk, except that any termination of this agreement for noncompliance with low-fat milk, skim milk, or cultured buttermilk which meets state and Title VI of the Civil Rights Act of 1964 shall be in accordance with local standards for such type of milk. applicable laws and regulations.

III. POLICY STATEMENT The Sponsoring Agency assures the State Department of Public Instruction that milk served under the Special Milk Program will be the same for and served in the same manner to all children wishing to participate in the program in all sites in which the program is offered and that the milk shall be provided without physical segregation of or discrimination against any child on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities).

IV. CERTIFICATION STATEMENT 1. I CERTIFY that the information on this Permanent Agreement/Policy statement and all related attachments is true and correct to the best of my knowledge 2. I UNDERSTAND that this information is being provided in connection with receipt of federal funds and that deliberate misrepresentation may subject me to prosecution under applicable state and federal criminal statutes. 3. By continuing to operate the SMP after the enactment or issuance of any changed or new statutes and regulations applicable to the Program covered by this Agreement and any changed and new instructions, policy memoranda, guidance and other written directives interpreting these statutes and regulations, the sponsoring organization agrees to comply with them. If the institution does not wish to comply with any changed or new items, the institution must seek to terminate the agreement in accordance with the terms outlined in this PI-1480-AP. 4. I FURTHER AGREE to abide by the terms and conditions of the Permanent SMP Agreement/Policy Statement and the Annual SMP Application.

V. SIGNATURES Name of Authorized Representative Name of DPI Representative Amanda Kane Title of Authorized Representative Title of DPI Representative Director, Community Nutrition Programs Signature of Authorized Representative Date Signed Mo./Day/Yr. Signature of DPI Representative Date Signed Mo./Day/Yr.   In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) Mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) Fax: (202) 690-7442; or (3) Email: [email protected] This institution is an equal opportunity provider.