PI-1463-C Child and Adult Care Food Program Nonprofit Food Service Financial Report For

Wisconsin Department of Public Instruction INSTRUCTIONS: Submit as detailed in Guidance Memorandum CHILD AND ADULT CARE FOOD PROGRAM (CACFP) 11 to: QUARTERLY FINANCIAL REPORT FOR SPONSORING WISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION ORGANIZATIONS OF UNAFFILIATED SITES COMMUNITY NUTRITION PROGRAMS PI-1463-C (Rev. 11-14) Attn.: CARI ANN MUGGENBURG PO BOX 7841 Completion of this information is a requirement of PL 95-627. MADISON, WI 53707-7841

FOR FISCAL QUARTER Check one October 1-December 31 April 1-June 30 Agreement Number Year 20 January 1-March 31 July 1-September 30

Name of Sponsoring Agency

Address Street, City, State, Zip

PROGRAM INCOME

1. Net income carried forward from prior fiscal quarter......

2. Federal reimbursement earned this quarter under the Child and Adult Care Food Program......

3. Income received this quarter from children and adults as payment for meals served......

4. Other food service program income received this quarter (Lines A + B + C + D) Specify...... $0.00

A. Food Service Interest Income...... $10

B......

C......

D......

5. TOTAL FOOD SERVICE INCOME LINES 1 + 2 + 3 + 4...... $0.00

CERTIFICATION

I CERTIFY, to the best of my knowledge, that this financial report is a true and accurate reflection of Child and Adult Care Food Program income and costs and that records are available to document these reported amounts. Signature of Authorized Representative Date Signed Mo./Day/Yr.  Title

PI-1463-C QUARTERLY ADMINISTRATIVE/OPERATIONAL FOOD SERVICE PROGRAM EXPENSES

Quarterly Administrative Costs 28. Total Operational Labor & Required Payroll Taxes 6. Total Administrative Labor & Required Payroll 29. Total Operational Benefits Taxes 7. Total Administrative Benefits 30. Total Operational Labor & Benefits (Line 28+29) $0.00 8. Total Administrative Labor and Benefits (Line 6+7) $0.00 31. Total Food Supplies 32. Total Nonfood Supplies 9. Equipment Purchased $5,000 and over 33. Equipment Purchased $5,000 and Over 10. Equipment Purchased under $5,000 34. Equipment Purchased Under $5,000 11. Office Supply Expense 35. Office Supply Equipment 12. Educational Supply Expense 36. Educational Supply Expenses 13. Printing Expense 37. Printing Expense 14. Postage Expense 38. Rent Expense 15. Office Rent Expense 39. Utilities Expense 16. Utilities Expense 40. Contracted Services 17. Insurance Expense 41. Equipment Rental/Lease Expense 18. Contracted Services 42. Telephone Expense 19. Equipment Rental/Lease Expense 43. Training/Travel Expense 20. Telephone Expense 44. Misc. Oper. Expense Specify 21. Advertising Expense 45. Total Operational Expenses 22. Dues, Subscription or Membership (Lines 31 thru 44) $0.00 23. Travel Expense 24. Training Expense 46.Total Operational Labor, Benefits, & Expenses (Lines 30+45) $0.00 25. Misc. Admin. Expense Specify 26. Total Administrative Expenses (Lines 9 thru 25) $0.00 47. Total Administrative and Operational Costs (Lines 27+46) $0.00

27. Total Administrative Labor, Benefits, and Expenses, (Lines 8+26) $0.00 48. Nonprofit Food Service Program Income (Line 5 – Line 47 = 0.00) $0.00 If line 48 is greater than line 5, enter 0