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SFSP-25, 3/87, RS 57-1421 <br /> ~.~;w STATE OF HAWAII NOTIFICATION OF AGREEMENT APPROVAL <br /> . ',~y,.,p.° ,DEPARTMENT OF EDUCATION <br /> j OFFICE of RuslNESS sERVlces RENEWAL OR CHANGE <br /> l School Food Services Branch <br /> //7 1106 Koko Head Avenue (Summer Food Service Program for Children) <br /> o Honolulu, Hawaii 96816-3797 <br /> i. Agreement Number 2. Action Code 3. Fiscal Year 4. Type of Sponsor 5. Type of Program <br /> E=ESTABLISH A. School 1. Sell-prep <br /> ok (New to master Ille) B. GOV Z. Vended <br /> digit C=CHANGE TO MASTER FILE C. Rea. Camp 3. Combination <br /> D. Others Sell-prep 8 Vended <br /> D=DELETE FROM MASTER FILE i't J, <br /> L i. <br /> a a <br /> 6. Name and Address of Service Institution (DO not exceed maximum line length) <br /> n - <br /> 7. Telephone Number 8. Contact Person <br /> 9. Meals Authorized (Enter 0, 1, or 2 indicating number of 10. Average Daily Number of 11. Days of Operation <br /> meal(s) per child to be served each day.) Children Served (estimate) (actual) <br /> Breakfast Lunch Supper Supplement June July August <br /> 12. Months Approved for Operation 13. Number of 14. Administrative 15. Request for Advance Payment <br /> o=NO r-res Self-Prep Sites Cost Limitations o=NO r--res <br /> June July August Dollars Atlmin Oper <br /> 0 0 ~ ~ r;.-~7! ~ n <br /> 16. Advance Authorization for Administrative Cost 17. Advance Authorization for Operating Cost <br /> (Whole Dollars Only) (Whole Dollars Only) <br /> First Atlvance Secontl Advance First Advance Secontl Advance Thirtl Advance <br /> 18. Number of Sites by Type <br /> A. Schools B. Government C. Resitlential Camps D. Otner <br /> 19. Comments <br /> =~wrT <br /> 20. Date of Preparation Signature Title <br /> Month Day Yeer <br /> m ~ ~ ~ ~ , <br /> <br /> DISTRIBUTION: ORIGINAL -DOE (White), Copy 1 -School Food Authority (Yellow), Copy 2 -Commodity Distribution Assistant (Pink) <br /> <br />