CACFP Agreement #____________
ORDER FORM FOR SPONSORS OF DAY CARE HOMES
In case we need to call:
Phone __________________________________________________________________________________
Package should be sent to the attention of ___________________________________
ALL ORDERS will be shipped to the Sponsor address on file
QUANTITY FORM #
Date __________________________________________
FORM NAME
QUANTITY FORM #
See FORM DESCRIPTIONS on Back
FORM NAME
1377
Crediting Foods in CACFP
CACFP-160
On-Site Provider Addendum
1378
Spanish 1377
CACFP-171
Day Care Home Child Menu
4066
And Justice for All poster
CACFP-171es Spanish CACFP-171
4364
Good Nutrition Pays in Day Care Homes
CACFP-173
4385
Chinese 4364
CACFP-173es Spanish CACFP-173
4386
Russian 4364
CACFP-182
4384
Spanish 4364
CACFP-199
4421
Together We Can Raise Healthy Children
4424
Chinese 4421
4427
French 4421
4428
Haitian-Creole 4421
CACFP-3978
4425
Korean 4421
CACFP-4118
4426
Russian 4421
4422
Spanish 4421
CACFP-102
Child Meal Pattern
CACFP-200
CACFP-3705
DOH-3805
DOH-4160
CACFP-102ar Arabic CACFP-102
DOH-4160es
CACFP-102zh Chinese CACFP-102
CACFP-102ht Haitian-Creole CACFP-102
DOH-4161
CACFP-102ko Korean CACFP-102
DOH-4161es
CACFP-102ru Russian CACFP-102
DOH-4219
CACFP-102es Spanish CACFP-102
DOH-4419
Child Meal Disallowance
Sample Child and Adult Care Menus
Day Care Home Infant Menu 6 Months to
1st Birthday
US and NYS Breastfeeding Labor Laws
Continuous Application and Agreement
for Day Care Home Participation
Order Form for Sponsors of Day Care
Homes
Monitor Checklist for Day Care Homes
Application for Start-Up or Expansion
Payments for Sponsoring Organizations
of Day Care Homes
Letter to Households/Income Eligibility
Form Tier II Day Care Home Participant
Spanish DOH-4160
Letter to Households/Income Eligibility
Form Family Day Care Home Provider
Spanish DOH-4161
CACFP-103ko Korean CACFP-103
DOH-5187
Provider Transfer Form
Child Enrollment Form for Day Care
Homes
Application for Close-Out Payments for
Sponsoring Organizations of Day Care
Homes
Day Care Home Breastfeeding Friendly
Self-Assessment
CACFP Fraud and Abuse Report Form
CACFP-103ru Russian CACFP-103
FNS-258
CD - Feeding Infants Guide
CACFP-103
Infant Meal Pattern
DOH-5063
CACFP-103ar Arabic CACFP-103
CACFP-103zh Chinese CACFP-103
DOH-5186
CACFP-103ht Haitian-Creole CACFP-103
CACFP-103es Spanish CACFP-103
Reference Chart for Provider Updates/
CACFP-104
Changes in CIPS
Pre-Approval Checklist for Enrolled
CACFP-106
Caregivers and Day Care Home Providers
CACFP-109
Sample Infant Menus
CACFP-127
Funding to Feed Children Outreach Flyers
Counties:________________________________________________________________________________
English
Chinese
Karen
MaayMaay
Haitian-Creole
Russian
Spanish
Claim Submission Deadlines
Ready, Set, Grow with WIC
English
Arabic
Chinese
French
Haitian Creole
Karen
Korean
Russian
Spanish
Vietnamese
Building for the Future
English
Arabic
Chinese
French
Haitian Creole
Karen
MaayMaay
Portuguese
Russian
Spanish
Vietnamese
This institution is an equal opportunity provider.
CACFP-3978 (4/17)
PAGE 1 OF 2
FORM DESCRIPTIONS
FORM #
DESCRIPTION
1377
Resource identifying reimbursable foods in CACFP
4066
Poster must be displayed at sponsor facility
4364
CACFP-104
Resource for providers explaining CACFP
Resource for parents explaining the benefits of
having a child care provider that participates in
CACFP
Chart indicating required components and minimum
quantities of food for children in care who are 1-18
years of age
Chart indicating required components and minimum
quantities of food for infants in care who are less
than 1 year old
Guidelines for submitting provider updates
CACFP-106
Document pre-approval visit for a new provider
CACFP-109
CACFP-182
Sample menus for infants
Chart indicating the 60-day postmark deadline for
monthly claims
Used to document changes in the on-site provider in
homes owned by another person or corporate entity
Menu planning form
Document monitoring of Day Care Home provider
meals
Sample daily menus for children
CACFP-199
Individual menu record for infant meals
4421
CACFP-102
CACFP-103
CACFP-127
CACFP-160
CACFP-171
CACFP-173
FORM #
DESCRIPTION
CACFP-3978
Breastfeeding labor laws that apply to all
participating sponsors and providers
Application and agreement for a day care home to
participate in CACFP
Order Day Care Home forms
CACFP-4118
Document required provider monitoring
DOH-3805
DOH-5187
Apply for start-up or expansion payments
Letter, income eligibility guidelines and application
for households of children participating in a Tier II
home. This form should be used to qualify children
in a Tier II home for Tier I rates.
Letter, income eligibility guidelines and application
for providers. This form should be used to document
eligibility to claim provider's own or resident
children and for Tier I eligibility verification.
Used by provider when transferring to another
sponsor
Record annual enrollment information for children
in day care homes
Apply for close-out payments
Apply for a DCH Breastfeeding-Friendly
Designation
Report fraud or abuse in CACFP
FNS-258
The Feeding Infants Guide is available on CD only
CACFP-200
CACFP-3705
DOH-4160
DOH-4161
DOH-4219
DOH-4419
DOH-5063
DOH-5186
Forms can also be found at www.health.ny.gov/CACFP
Submit your order
using ONE
of these options:

Mail to:
NYS DOH CACFP – Orders
150 Broadway Suite 650
Albany, NY 12204
Fax to:
OR
(518) 402-7252
Email to:
OR
[email protected]
No need for cover page
For information about an order placed with CACFP, call 1-800-942-3858
CACFP-3978 (4/17)
PAGE 2 OF 2