COM 0521.064 2002-2004 - Laserfiche WebLink

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SFSP-25, Rev. 4/03, RS 03-1286 Rev. of RS 87-7427 i STATE OF HAWAII 4 NOTI~IGAjION OF AGREEMENT APPROVAL ry%_° 'N'>rr DEPARTMENT OF EDUCATION ' I( - j School Food Services Branch RENEWAL OR CHANGE g(17 ~ 1106 Koko Head Avenue ~;~.~e Honolulu, Hawaii ss6,s-3~s~ (Summer Food Service Program for Children) 1. Agreement Number 2. Action Code 3. Fiscal Year 4. Type of Sponsor 5. Type of Program E=ESTABLISH A. School 1. Sell-prop ok (New to master /lie) B. GOV 2. Vsndsd digit C=CHANGE TO MASTER FILE C. Rn. Camp 3. Com0lnetlon D. Other SNI-prop 8 Vsndsd r/ ~ _ ® D=DELETE FROM MASTER FILE , i O a a 6. Name and Address of Service Institution (Do not exceed maximum Ilne length) Cola njr v c~ ~+i r~r~R ~ ~~C 1-LA N~ ~1V~N UE Nl L ~ 1tI (~'~~C' 7. Telephone Number 8. Contact Person ~~=1C~i-"14(7 aF:~~NE MZ~AKE 9. Meals Authprized (Enter 0, 1, or 2 Indicating number of 10. Average Dally Number of 11. Days of Operation mesf(s) per child to be served each day.) Children Served (estimate) (actual) Broeklasl Lunch Supper SuDplsmenl June July August U © ! 5~ O I I I In 12. Months Approved for Operation 13. Number of 14. Administrative 15. Request for Advance Payment o=NO r-res Self-Prep Sites Coat Limitations a=NO t=res June July August Dollars Admin Oper 16. Advance Authorization for Administrative Coat 17. Advance Authorization for Operating Coat (Whole Dollars Only) (Whole Dollars Only) Flrsl Advance Seeond Advance First Adven<a Second Advenca Third Atlvencs 18. Number of Sites by Type A. Schools B. Government C. Resltlenllal Camps D. Other c~ Q 19. Comments 20. Date of Preparation Signature Title Month Day rear j I ¢ C I Ci /"1 ~ ~~~~/C~GL~'LfL ~ ~r~,i l%~L ~i_G nG_Ci~. ~l/~% ~-~/~YIJ /iJ II ~.I v ~ / DISTRIBUTION: ORIGINAL -DOE (White), Copy 1 -School Footl Authority (Yellow), Copy 2 -Commodity Distribution Assistant (Pink)