Oregon Department of Education, School Nutrition Team

Paid Lunch Equity Annual Exemption Request for SY 2015-16

SFA Information
Name of Sponsor:: / Date:
Contact Person: / Contact Phone:
Mailing address: / Contact Email:
Summer Contact Information: / Agreement Number:
Assessment Questions: Please provide thorough, concise answers to the following
Does the sponsor anticipate non-federal funds being transferred into the nonprofit school food service account?
Yes, How much? $ No
Does the sponsor anticipate starting a new program?
Fresh Fruit and Vegetable Yes, estimated cost? $ No
School Breakfast Yes, estimated cost? $ No
Afterschool Snack Yes, estimated cost? $ No
Has the sponsor evaluated the fiscal impact of Smart Snacks starting July 1, 2014?
Yes, estimated budgetary impact estimated Revenue > or $
Estimated Expenses?
No, explain
Is the sponsor certified to receive the additional six cents funding for lunches Yes No
Has the sponsor evaluated the cost for future meal pattern requirements (e.g. future sodium targets)?
Yes, estimated cost? No
Does the sponsorhave sufficient resources to budget for equipment, maintenance repair and replacement?
Yes, explain No, explain
Does the sponsor routinely defer equipment maintenance, repair and replacement?
Yes, explain No, explain
Sponsor plans to purchase equipment in the next 2-5 years for the kitchen and/or cafeteria
Yes, estimated cost? $ No
Does the sponsor currently include students in meal planning, taste testing, and wellness policy?
Yes, explain how No
Sponsor has met previous PLE requirements. Yes, by (mark method used):
Increased Prices Used Non-federal funds Used a combination of price increases and non-federal funds
No, explain
References: PLE memos, SP 39-2011, SP 39-2011 revised, SP 34-2013, SP 58-2013, , SP 28-2014, SP 03-2015

Does the sponsor currently utilize signage, food placement and marketing techniques to promote healthy selection of reimbursable meals? Yes, explain how No, explain
Does the sponsor currentlyutilize salad bars that include a variety of fruits and vegetables?
Yes, # of fruits, available daily # of vegetables, available daily
No, explain
Has the sponsor had to reduce labor costs due to insufficient funds? Yes, explain No, explain
Has the sponsor reduced hours? Yes, explain No, explain
Has the sponsor eliminated positions? Yes, explain No, explain
Does the sponsor have all child nutrition staff vacancies filled? Yes No, explain
Other fiscal impacts on sponsor’s child nutrition programs. Explain
Has the sponsor evaluated the cost of meeting NSLP Professional Standards requirements?
Yes No, explain
Is the sponsor is currently meeting all non-program food revenue requirements. Yes, explain
No, explain
References:SP 39-2011 revised, SP-13-2014

Does the sponsor anticipate improvements in food quality? Yes, estimated cost? $ No
Revenues and Expenditures (Nonprofit Food Service Account)
Provide numbers from 2013-14 Year End
Beginning Balance:
Total Expenditures:
Total Revenues:
Year Ending Balance:
Number of Months Operating: / Provide YTD numbers for 2014-15
Report Month:
% of fiscal year represented:
Beginning Balance:
Total Expenditures:
Total Revenues:
Ending Balance:
Meal Prices and Paid Lunch Equity Calculations
Provide information from the Paid Lunch Equity Tool and attach completed tool.
Paid Lunch Price(s) for 2014-15 SY:
Anticipated Weighted Average Paid Lunch Price for 2015-16 SY:
Anticipated Paid Lunch Price(s) for 2015-16 SY:
Amount of Non-Federal Funding received and utilized when determining meal prices* for the 2015-16 SY:
(*The proportion of state match attributable to paid meals may be used as non-federal funds to meet PLE)
Number of Paid Lunches Served in the 2012-13 SY:
Number of Paid Lunches Served in the 2013-14 SY:
Return completed form to
Information and Notes (State Agency use only)
Sponsor is “In Compliance” with last Administrative or CRE Review.
Sponsor has made menu improvements to encourage students to eat healthier meal/program attractive
Sponsor’s certification (eligibility to POS) process using best practices to prevent overt identification
Sponsor using best practices to improve access via Direct Certification including homeless, runaway, migrant, foster
Sponsor has all child nutrition staff vacancies filled
(If vacancies are primarily due to lack of funding, rather than other factors, an exemption should not typically be approved)
3 month average expenditure calculation:
(Total Expenditures/Number of Months Operating x 3)
Excess cash available for PLE from 2014-15 SY:
(Year Ending Balance – 3 Month Average Expenditures)
Projected excess cash available if increase meal price for 2015-16 SY:
(Anticipated Paid Meal Price for 2015-16 SY x Average Number of Paid Meals Served in 2013-14 SY)
Approval Yes
Recommendation No / CN Specialist assigned to Sponsor:
/ Date: ______
Approval Yes
Recommendation No / School Financial Specialist:
______/ Date: ______
Approved __ Denied _____ / Manager – SNP
______/ Date:
Form process:
AS1 save in SNP/Paid Lunch Equity/SY/exemption request/Sponsor Name.
ODE Child Nutrition Specialistand School Financial Special makes recommendation insert signature and Rename to “Sponsor Name Approved/Denied”
Manager approves or denies

K:\~Memos\_SNP Memos-Unnumbered\2014-15\Paid Lunch Equity\PLE_exemptionrequest_1516_OR Final.doc