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SFSP-25, 3/87, RS 87-142, <br />STATE OF HAWAII <br />DEPARTMENT OF EDUCATION <br />1 OFFICE OF BUSINESS SERVICES <br />2 li School Food Sr°rvices Rmnch <br />1106 Kokoaii 9f,016 379i Avenue <br />Honolulu. Hawaii <br />NOTIFICATION OF AGREEMENT APP �i�VAL <br />RENEWAL. OR CHANGE <br />(Summer Food Service Program for Children) <br />1. Agreement Number <br />2. Action Code <br />3. Fiscal Year <br />4. Type of Sponsor <br />5. Type of Program <br />ok <br />digit <br />❑��D. <br />— <br />a <br />E ESTABLISH <br />(New to master tile) <br />C CHANGE TO MASTER FILE <br />D -DELETE FROM MASTER FILE <br />A. School <br />B. GOV <br />C. Res. Camp <br />Others <br />1. Sell -prep <br />2. Vended <br />3. Combination <br />Self -prep b Vended <br />H <br />6. Name and Address of Service Institution (Do not exceed maximum line length) <br />t -I - _ - -- - ❑ ! <br />i <br />7. Telephone Number <br />I <br />8. Contact Person <br />❑❑ <br />9. Meals Authorized (Enter 0, 1, or 2 indicating number of <br />meal(s) per child to be served each day.) <br />10. Average Daily Number of <br />Children Served (estimate) <br />11. Days of Operation <br />(actual) <br />Breakfast Lunch Supper Supplement <br />❑ ❑ ❑ ❑ <br />June July August <br />M / [D- <br />2. Months Approved for Operation <br />2. <br />O -NO 1=YES <br />13. Number of <br />Self -Prep Sites <br />14. Administrative <br />Cost Limitations <br />15. Request for Advance Payment <br />O -NO 1 -YES <br />June July August <br />❑ ❑ ❑ <br />❑❑ <br />Dollars <br />Admin Oper <br />❑ ❑ <br />16. Advance Authorization for Administrative Cost <br />(Whole Dollars Only) <br />17. Advance Authorization for Operating Cost <br />(Whole Dollars Only) <br />First Advance Second Advance <br />First Advance Second Advance Third Advance <br />18. Number of Sites by Type <br />A. �Schools B. Government C. Residential Camps D. Other <br />19. Comments <br />10. Date of Preparation Signature <br />Title <br />Month Day Year <br />❑ ❑ ❑ <br />DISTRIBUTION: ORIGINAL - DOE (White) Copy 1 - School Food Authority (Yellow), ,op <br />