VERIFICATION SUMMARY REPORT – Form 742SD
National School Lunch Program (NSLP)
/ I. Local Agency InformationA. Local Agency Name & Number(7 digits) ______
B. Type Of Local Agency Public or Government Private
C. This agency has no students eligible for free or reduced price meals.
D. This agency is an RCCI with only residential students (no day students).
E. Number Applications on file Oct. 1______(equals the sum of Column B 4.2, 4.3
and 5.)
F. Number Applications Selected for Verification______(equals the sum of # applications in questions 7 thru 11).
G. Date Verification was completed:______
SOUTH DAKOTA DEPARTMENT OF EDUCATION –
Child & Adult Nutrition Services
Report is due December 15. All local agencies must complete all boxes except those marked with an asterisk (*). That includes including those with breakfast-only sites, those with Provision 2 or 3 attendance centers establishing a new base year, and those with Provision 2 or 3 breakfast only attendance centers. Provision 2 and 3 local agencies claiming lunch count percentages based on a prior base year complete only the boxes that are marked with an asterisk (*).
II. Enrollment, Application and Eligibility Information /
III. Results of Verification by Application Type
(Based on Information Provided by Households)1. Type of Free/Reduced Price Application Used
Individual Student Household Both / 6. Type of Verification Used:
Basic Alternate-Random Alternate-Focused No Verification Performed
Report Free and Reduced Price Application information for your Local Agency in items 2 through 5 according to the dates specified. / A. All LAs
Including Provision 2 & 3 base year and Breakfast only / B. Provision
2 & 3 LAs
which are not operating in a base year / Items 7 through 11 are required and are reported as of the date of completion of the verification process. Complete unshaded areas in columns A, B and C. / A.
FREE ELIGIBLE based on FS/TANF/FDPIR Application (Categorically Eligible) / B.
FREE ELIGIBLE based on Income/Household Size Application (Income Eligible) / C.
REDUCED PRICE ELIGIBLE
2. Number of attendance centers operating the NSLP and/or SBP as of last operating day in October / *
3. Number of enrolled students with access to NSLP (or only SBP) as of last operating day in October / * / 7. No Change / # applications
Complete unshaded boxes in columns A and B to answer the items 4 -5. / A. Number of Eligible Students
as of Oct 31 / B. Number of Approved Applications
as of October 1 / # students
8. Responded, Changed from Reduced to Free / # applications
4. Total FREE eligible
(Total of column A, 4.1- 4.4 should equal this number) / as of Oct 31 / # students
4.1) Number approved as FREE eligible who are not subject to verification due to direct certification; homeless, runaway and migrant lists; income-eligible Head Start and
pre-K Even Start; residential students in RCCIs; and non-applicants approved by local officials) / as of Oct 31 / 9. Responded, Changed from Free to Reduced / # applications
# students
4.2) Number approved as FREE eligible based on Food Stamp/TANF/FDPIR case number submitted on an application (Categorically Eligible) / as of Oct 31 / as of Oct 1 / 10. Responded, Changed from Free or Reduced to Paid / # applications
# students
4.3) Number approved as FREE eligible based on income/household size information submitted on an application. This includes foster children. (Income Eligible) / as of Oct 31 / as of Oct 1 / 11. Did Not Respond, Changed to Paid / # applications
# students
4.4) Number FREE eligible reported for provision 2 & 3 schools which are not operating a base year / as of Oct 31 * / IV. Name of Person completing Form:______
Phone number & E-mail:______
Date Verification Summary Report submitted to CANS:______
Due to Child & Adult Nutrition Services-DOE on or before by December 15
5. Total REDUCED PRICE eligible. / as of Oct 31 / as of Oct 1
5.1) Number REDUCED PRICE eligible reported for Prov 2 & 3 schools which are not operating a base year / as of Oct 31 *