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OFFICIAL SITE OF THE STATE OF NEW JERSEY
Department of Agriculture
Division of Food and Nutrition
Child and Adult Care Food Program (CACFP) - Outreach
Outreach and Eligibility Determination Form
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Required
Institution Name
Legal Address (NJ Physical Office Location)
Address Line 1
Address Line 2
City
County
Please Select
Atlantic
Bergen
Burlington
Camden
Cape May
Cumberland
Essex
Gloucester
Hudson
Hunterdon
Mercer
Middlesex
Monmouth
Morris
Ocean
Passaic
Salem
Somerset
Sussex
Union
Warren
State
ZIP
ZIP Code
Extension
Institution Contact (Responsible Principal)
Name
Title
Phone #
Extension
Email Address
Does your Institution participate in the Preschool Expansion Aid (PEA) / Universal Preschool Program?
Yes
No
I Don't Know
Please choose an option that best fits the description of your day care program:
I operate one or more childcare/head start/infant preschool program(s)/before and after care for children under 13 years of age.
I operate a day care program for disabled adults or adults over 60 years of age.
I operate one or more after school programs for children up to 18 years of age.
I operate an emergency shelter for parents/guardians with children.
I operate a day care from my home.
I want to sponsor family day care homes.
What is your institution's tax-exempt status?
Non-profit
For-profit (Not Eligible to Sponsor Family Day Care Homes)
Military
Government
Do you have tax-exempt status from the IRS under section 501(c)(3) of the Internal Revenue Service?
Yes
No
Is your institution a religious organization?
Yes
No
Can you confirm that at least 25% of the children enrolled in your day care are classified as "low-income?"
Yes
No
I Don't Know
Does your facility possess a license?
Yes
No
Please select which of the following options applies best to your program:
We are an adult care facility permitted to operate through the Department of Health.
We operate an afterschool program for children ages 12-18 in a low-income area which does not require licensure.
We operate an emergency shelter and do not require a facility license to operate.
We are a family day care sponsoring organization; our providers all possess facility licenses.
We are a new institution waiting for our facility license to be processed.
We are a program who does not possess a facility license and/or documentation from state or local officials for compliance with health and safety standards.
All centers are required to meet all applicable state or local health and safety standards. If a center is not able to produce a facility license, it may still be possible to participate in CACFP. Please select the option below that best applies:
We are an adult care facility and have a current Certificate of Occupancy, Sanitation Certificate, and Fire Zone Certificate.
We are an afterschool program and have a current Certificate of Occupancy, Sanitation Certificate, and Fire Zone Certificate.
We are an emergency shelter and have a current Certificate of Occupancy, Sanitation Certificate, and Fire Zone Certificate.
We are a family day care sponsoring organization; our providers meet all applicable state or local health and safety standards.
We are a new institution and waiting for our facility license, Sanitation Certificate, and Fire Zone Certificate to be processed. I understand that if my facility license does not have a maximum capacity listed, a Certificate of Occupancy will be required to verify capacity for our building.
We are in the process of undergoing inspections to obtain our Sanitation Certificate and Fire Zone Certificate. We understand we will be expected to produce these documents upon receipt.
We do not plan to undergo inspections from local state and/or health officials.
How long has your daycare center been in operation?
How many participants are currently enrolled in your center?
Submit
OFFICIAL SITE OF THE STATE OF NEW JERSEY