WPC V.]W-D% Q-N,Ifg }0eoYmC奔.HkYg:Zl :Q>M䔶v [ joZU#klOgR=U/{(b@=eEGRV Z FHGFDgiW#R*!Mجo|\Q)2uQq ?"WĐ04U:G H="<`tZLZv}_MB ڒn]bo5BCP=}*0pȸ$ tPr'rbkKaќ4>#8Ye)"2>cGD1[ʅa3&: w[:|3kWKyz H&?zp12**Ec#n#d UD:% %_ 0ef%a'f;a=fQaS^ gws4w mfafafafaf a f!f#a%a9fMaOfcaefya{fafafafafafafaf)a+f?aAfUaWfkamfafafafafafaf af%a'f=a?fUaWfmaofafafafaffa Baaf2f4a6aLfbfdaff|a~fafafafafaf af$a&f<a>fTaVflanfafafafafafaaf*f,f.a0aFa\fratf B*fafaafafaf,a...fDaFFFFFFFFFFFFFFFFFFFFFFFFFFFFF B5\\\SRS\srpdp39hp,,,,,,0,  AZ"Arial RegularX(u$USUS.,?(XX" ?( "r_r<"_JE("<]* (JE0* ]!20* %2!261%* 6TABLE Ah|TABLE C TABLE DL,)L V),)݂Backup3|xUTABLE B{TABLE EZTABLE FTABLE HlTABLE G莨xTABLE ITABLE JȡTABLE K}TABLE L{TABLE MTABLE N{TABLE OZTABLE PTABLE QxFTABLE R}TABLE S{TABLE TTABLE UTABLE VTABLE W`TABLE X{TABLE YTABLE AAHTABLE Z}TABLE ACHTABLE ABPTABLE ADTABLE AFPTABLE AGTABLE AE`TABLE AH{TABLE AI}TABLE AJTABLE AKUTABLE ALTABLE AM}TABLE AO dTABLE AN00TABLE APTABLE AQTABLE AR*TABLE AS]TABLE AT(TABLE AUضTABLE AV(TABLE AW(TABLE AXضTABLE AY TABLE AZ*TABLE BApTABLE BBTABLE BCpTABLE BD{TABLE BEOTABLE BF^TABLE BGTABLE BHTABLE BITABLE BJ TABLE BMTABLE BKTABLE BLpTABLE BPh+&0 d d(PTABLE BN3TABLE BOTABLE BQ TABLE BRpTABLE BSTABLE BTh+TABLE BU1Large Dashed d u!USUS.,?(XX" ?( "r_r<"_JE("<]* (JE0* ]!20* %2!261%* 6  _XX8JXXdd8*\ddd Xdd Xdd X$$,xdd +  XX   ExhibitA 0&!d0 0  STATEOFKANSAS 2 DEPARTMENTOFSOCIALANDREHABILITATIONSERVICES 0&!  0   NUTRITIONPROGRAMFORTHEELDERLY P USDAFOODCOMMODITYAPPLICATION/AGREEMENT  $ 1'%    1*l\ddX dd x\$$l,gdd ,?dd ,dd +     '&612 $n   $   **Note:TheRecipientFacilitymustcompletethisform,buttheRecipientFacilityandthe n   FacilityssupervisingProjectmustsignthisform. !   !(n    (#261&'#*\ddgdd g?dd ?dd \$$,dd ,zdd +      JE(612PARTA. '/   ' DESCRIPTIONOFRECIPIENTFACILITY (/   (* \ dddd zdd z\$$,dd ,edd ,dd +  - -   '9   ' SectionI. '9   ' IdentifyingInformation (9   (*\dddd edd edd  \ $$,dd ,wdd ,edd ,Qdd ,;dd +  7 7   '   'A. '   'Facility   Name: .\\ . ' \ ' '  ' ' ' ' 'Address: ' ' ' ' ' ''&(JE '9  ' '9   ' '9! 'ЀStreetCityStateZip '9"  ' '9# 'JE(&' '1$ ' '1% 'Mailing 1& Address: $J' $  1(  '1) ''&(JE 'T*  ' 'T+  ' 'T, 'ЀStreetCityStateZip 'T-  ' 'T. 'JE(&' '/  ' '0  'Telephone 1 Number: $e2 $  3  '4 ''&(JE '5 ' '6 ' $7 $  8  '9 '#JE(&'# 'o: ' 'o; 'Contact o< Person: '0= ' 'o> ' 'o? ' ':@  ' ':A  ' ':B '  Title 0&!:C0  0(:D   (*\d ddd wdd wedd eQdd Q;dd ;\$$,dd ,wdd ,dd +  8D8  'E ' 'F '  Pleaseprovideanyadditionalinformationthatmaybenecessarytomakeadeliverytoyourfacility.  ]H  0&!v!I 0 '" J  ' .\" K . '" L\ ' ':$!M ' ':$!N 'Pleaselistanyotherlocationsthatyouprovidemealsfor. $"P  '%d#Q ' ''$R  ' .\'$S . ''$T\ ' 'A)&V  ' '((&W  'Pleaseprovidetheaveragedailynumberofmealsserved.(A)&Y    (*\dddd wdd wdd \$$,dd ,wdd ,dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd +  ?*'Y?*'  'd+ )[  ' '*K(\  'Breakfast 'd+ )^ ' '*K(_ 'Lunch 'd+ )a ' '*K(b 'Dinner 'd+ )d ' '*K(e 'Other 'd+ )g '(*K(h  (*\d ddd wdd wdd dd dd dd dd dd dd dd \$$,dd ,wdd ,dd ,dd , dd +  b, *hb, *  ',n*i  ' ',n*j  'Howmanydaysperweekaremealsserved? '-/+l ' ',n*m '(,n*n  ( .-,n *\dddd wdd wdd dd  dd \$$,dd ,edd ,dd +  XX (JE& % 'd  ' SectionII. 'd  ' FoodServiceOperations (d  (#%& #*\dddd edd edd \$$,dd ,hdd +  pp & % ',  'Pleaseprovidethefollowinginformation.(,  (*\ dddd hdd h\$$,dd ,wdd ,dd +  88  'D  'A. 'D  'ALLSTORAGEAREAS(D  (*!\"dddd wdd wdd \ $$,dd ,wdd ,wdd ,zdd +  PP  '    ' G=     ?1.? G_1._ F<7    ?1. ?  F  DoestheFacilitydatestamporotherwiseidentifythefoodproductsinordertoassurethat    productsdonotbecomeoutdatedandareusedona firstin/firstoutbasis?1'%   1*#\$dddd wdd wwdd wzdd z!\"$$,dd ,wdd ,wdd , dd ,Xdd , dd ,dd +     'J   ' 'J   ' 'J  ' 'J  'Yes 'J  ' 'J  'No(Ifno,pleaseexplain)(J   (*%\&dddd wdd wwdd w dd Xdd X dd dd #\$$$,dd ,wdd ,wdd ,zdd +  V V   ' b  ' ' b  ' ' b '( b  (*'\(dddd wdd wwdd wzdd z%\&$$,dd ,wdd ,wdd ,dd ,wdd , dd ,wdd ,dd +   n  n   '*   ' G=*    @2.@ G_2._______________________________ F<7*   @2. @  F%& Isthefoodproperlysecuredtopreventloss?#& %0# '*  ' '*  'Yes '*  ' '*  'No(Ifno,pleaseexplain)(*   (*)\*dddd wdd wwdd wdd wdd w dd wdd wdd '\($$,dd ,wdd ,wdd ,zdd +  6 6   ' B !  ' ' B "  ' ' B # '( B $  (*+\,dddd wdd wwdd wzdd z)\*$$,dd ,wdd ,wdd ,zdd +  N $N   '  %  ' G=  &   @3.@ G_3._ F<7  '  @3. @  FDoestheFacilityhaveapestcontrolcontractsufficienttoprotectUSDAcommodities?(  (  (*-\.dddd wdd wwdd wzdd z+\,$$,dd ,wdd ,wdd ,Xdd ,Xdd , dd ,dd +   (   'z")  ' 'z"*  ' 'z"+ ' 'z", 'Yes 'z"- ' 'z". 'No(Ifno,pleaseexplain)(z"/  (*/\0dddd wdd wwdd wXdd XXdd X dd dd -\.$$,dd ,wdd ,wdd ,zdd +  ./.  '0  ' '1  ' '2 '(3  (*1\2dddd wdd wwdd wzdd z/\0$$,dd ,wdd ,wdd ,wdd ,m dd ,dd +  3  'Z4 ' 'Z5 ' 'Z6 'a. 'Z7 'Contractwith(specifycompany) 'Z8 ' 'Z9 ' 'r:  ' 'r;  ' 'r<  'b. 'r=  'HowoftenistheFacilitytreated? 'r> '(r?   (*3\4dddd wdd wwdd wwdd wm dd m dd 1\2$$,dd ,wdd ,wdd ,wdd ,dd +  ~?~  ':@  ' ':A  ' ':B  'c. ':C  'Onthelastpestcontrolreport,werethereanyproblems?(:D  (*5\6dddd wdd wwdd wwdd wdd 3\4$$,dd ,wdd ,wdd ,wdd , dd , dd , dd ,dd +  FDF  'RE  ' 'RF  ' 'RG  ' 'RH ' 'RI 'Yes .\RJ . 'RK\ 'No(Ifyes,pleaseexplain)(RL  (*7\8dddd wdd wwdd wwdd w dd  dd  dd dd 5\6$$,dd ,wdd ,wdd ,wdd ,dd +  ^L^  'M  ' 'N  ' 'O  ' 'P '(Q  (*9\:dddd wdd wwdd wwdd wdd 7\8$$,dd ,wdd ,wdd ,dd ,wdd , dd ,wdd ,dd +  &Q&  '2R  ' G=2S   @4.@ G_4._ F<72T  @4. @  F%& Areallstorageareasneat,orderlyandmoisturefree?#& %I# '2U ' '2V 'Yes '2W ' '2X 'No(Ifno,explain)(2Y  (*;\<dddd wdd wwdd wdd wdd w dd wdd wdd 9\:$$,dd ,wdd ,wdd ,zdd +  >Y>  'Z  ' '[  ' .\\ . ']\ ' 'j^  ' G=j_   @5.@ G_5._ F<7j`  @5. @  FAreallstorageareas(dry,refrigerated,frozen)equippedwiththermometers?(ja   (*?\@dddd wdd wwdd wzdd z;\<$$,dd ,wdd ,wdd ,Rdd ,%dd ,%dd ,dd +  vav  'b  ' 'c  ' 'd  ' 'e 'Yes .\f . 'g\ 'No(Ifno,pleaseexplain)(h  (*=\>dddd wdd wwdd wRdd R%dd %%dd %dd ?\@$$,dd ,wdd ,wdd ,zdd +  h  'J i  ' 'J j  ' .\J k . 'J l\ ' '!bm  ' G=!bn   @6.@ G_6._ F<7!bo  @6. @  FDoestheFacilityplanto(orcurrently)usecommercialstoragefacilities?(!bp   (*C\Ddddd wdd wwdd wzdd z=\>$$,dd ,wdd ,wdd ,dd , dd ,dd ,dd +  "n p"n   '*# q  ' '*# r  ' '*# s  ' '*# t 'Yes .\*# u . '*# v\ '  No(Ifyes,listcompany,storageaddress,andattachacopyofthe1'%*# w  1*A\Bdddd wdd wwdd wdd  dd dd dd C\D$$,dd ,wdd ,wdd ,/ dd ,Kdd +  6$!w6$!  '$B"x  ' '$B"y  ' '$B"z  'currentstorageagreementorcontract) .\$B"{ .($B"| \ (*E\Fdddd wdd wwdd w/ dd / Kdd KA\B$$,dd ,wdd ,wdd ,zdd +  %N#|%N#  ' &#}  ' ' &#~  ' .\ &# . ' &#\ ' 'z'"% ' G=z'"%  @7.@G_7._ F<7z'"%  @7. @ FDoestheFacilityplantoemploytheservicesofafoodservicemanagementcompany 'z'"% ' '(&  ' '(&  ' '(&  'toconductitsfoodserviceoperations?((&   (*K\Ldddd wdd wwdd wzdd zE\F$$,dd ,wdd ,wdd ,dd , dd ,dd ,dd +  )')'  'Z*(  ' 'Z*(  ' 'Z*(  ' 'Z*( 'Yes .\Z*( . 'Z*(\ '  No(Ifyes,listcompany,andattachacopyofthecurrentagreementor1'%Z*(  1*G\Hdddd wdd wwdd wdd  dd dd dd K\L$$,dd ,wdd ,wdd ,dd , dd +  f+)f+)  '+r)  ' '+r)  ' '+r)  'contract,andcompleteandattachExhibitF) .\+r)  .(+r) \ (*I\Jdddd wdd wwdd wdd  dd G\H$$,dd ,wdd ,wdd ,zdd +  ,~*,~*  ':-*  ' ':-*  ' .\:-* .(:-* \ ( F.+ *M\Ndddd wdd wwdd wzdd zI\J$$,dd ,dd ,dd +  XX %&  'd  'B. 'd  'DRYSTORAGEAREA(d  (*O\Pdddd dd dd M\N$$,dd ,wdd ,wdd ,m dd ,dd , dd ,dd ,| dd +  \\  '  ' G=   ?1.? G_1._ F<7  ?1. ?  FArethefoodsstoredoffthefloor? ' ' ' 'Yes '  ' '  'No(Ifno,pleaseexplain)(   (*Q\Rdddd wdd wwdd wm dd m dd  dd dd | dd | O\P$$,dd ,wdd ,wdd ,zdd +     't   ' 't   ' .\t .(t \ (*S\Tdddd wdd wwdd wzdd zQ\R$$,dd ,wdd ,wdd ,dd ,bdd +  ll  'x  ' G=x   @2.@ G_2._ F<7x  @2. @  FWhatistheaveragetemperatureatwhichthefoodsarestored? 'x '(x  (*U\Vdddd wdd wwdd wdd bdd bS\T$$,dd ,wdd ,wdd ,dd ,,dd , dd ,,dd ,dd +  pp  ',  ' G=,   @3.@ G_3._ F<7,  @3. @  FIsthereadequateventilationinalldrystorageareas? ', ' ', 'Yes ', ' ', 'No(Ifno,explain)(,  (*W\Xdddd wdd wwdd wdd ,dd , dd ,dd ,dd U\V$$,dd ,wdd ,wdd ,zdd +  $ $   ' 0  ' ' 0  ' .\ 0 . ' 0 \ ' ' !  ' G= "   @4.@G_4._ F<7 #  @4. @ FIsthefoodstoredapartfromanyproductornonfooditemswhichmightcontaminateor( $   (*Y\]dddd wdd wwdd wzdd zW\X$$,dd ,wdd ,wdd ,dd ,dd ,dd ,dd , dd +   $   '@ %  ' '@ &  ' '@ '  'spoilthecommodities? '@ ( ' '@ ) 'Yes '@ * ' '@ + 'No(@ ,  (*Z\[dddd ydd wydd wdd dd dd dd  dd Y\]$$,dd ,dd ,dd +  8 ,8   ' D -  'C. ' D .  'REFRIGERATOR/COOLERSTORAGEAREA( D /  (*_\`dddd dd dd Z\[$$,dd ,wdd ,wdd ,zdd +  < /<   ' 0  ' G= 1   ?1.? G_1._ F<7 2  ?1. ?  FWhatistheaveragerefrigerator/coolertemperatureatwhichthefoodsarestored?( 3  (*^\adddd wdd wwdd wzdd z_\`$$,dd ,wdd ,wdd ,dd ,wdd ,dd ,wdd ,dd ,wdd ,dd +   3   'T 4  ' 'T 5  ' 'T 6  '(Specifytemperatureineachrefrigerator/cooler) F<T 7   ?1?F1. E;6T 8  ?1 ? E G=T 9  @2.@G_2._ F<7T :  @2. @ F F<T ;  @3@F3. E;6T <  @3 @ E(T =  (*c\dd ddd wdd wwdd wdd wdd wdd wdd wdd wdd wdd ^\a$$,dd ,wdd ,wdd ,dd ,,dd , dd ,,dd ,dd +  L=L  'X>  ' G=X?   @2.@ G_2._ F<7X@  @2. @  FArethefoodsstoredoffthefloorinwalkincoolers? 'XA ' 'XB 'Yes 'XC ' 'XD 'No(Ifno,explain)(XE  (*e\fdddd wdd wwdd wdd ,dd , dd ,dd ,dd c\d$$,dd ,wdd ,wdd ,zdd +  PEP  ' F  ' ' G  ' .\ H .( I \ (*g\hdddd wdd wwdd wzdd ze\f$$,dd ,dd ,dd +  I  'hJ  'D. 'hK  'FREEZERSTORAGEAREA(hL  (*i\jdddd dd dd g\h$$,dd ,wdd ,wdd ,zdd +  `L`  'lM  ' G=lN   ?1.? G_1._ F<7lO  ?1. ?  FWhatistheaveragefreezertemperatureatwhichthefoodsarestored?(lP  (*k\ldddd wdd wwdd wzdd zi\j$$,dd ,wdd ,wdd ,dd ,wdd ,dd ,wdd ,dd ,wdd ,dd +  dPd  ' Q  ' ' R  ' ' S  '(Specifythetemperatureineachfreezer) ' T  '1. ' U ' G= V  @2.@G_2._ F<7 W  @2. @ F ' X '3. ' Y '( Z  (*m\nd ddd wdd wwdd wdd wdd wdd wdd wdd wdd wdd k\l$$,dd ,wdd ,wdd ,dd , dd , dd ,dd ,dd +  Z  '|$[  ' G=|$\   @2.@ G2. F<7|$]  @2. @  FArethefoodsstoredoffthefloorinwalkinfreezers? '|$^ ' '|$_ 'Yes '|$` ' '|$a 'No(Ifno,explain)(|$b  (*o\pdddd wdd wwdd wdd  dd  dd dd dd m\n$$,dd ,wdd ,wdd ,zdd +  tbt  'c  ' 'd  ' .\e .(f \ (*q\rdddd wdd wwdd wzdd zo\p$$,dd ,dd ,dd +  xfx  '4g  'E. '4h  'INVENTORY(4i  (*s\tdddd dd dd q\r$$,dd ,wdd ,wdd ,zdd +  ,i,  '8j  ' G=8k   ?1.? G1. F<78l  ?1. ?  FPleasedescribetheFacilitysinventory/usagesystemandrecordkeepingproceduresregarding(8m  (*u\vdddd wdd wwdd wzdd zs\t$$,dd ,wdd ,wdd ,zdd +  0m0  'n  ' 'o  ' 'p 'thereceipt,storageanduseoffoods.(q  (*w\xdddd wdd wwdd wzdd zu\v$$,dd ,wdd ,wdd ,zdd +  q  'Hr  ' 'Hs  ' .\Ht .(Hu \ (*y\zdddd wdd wwdd wzdd zw\x$$,dd ,wdd ,wdd ,zdd +  @ u@   ' Lv  ' ' Lw  ' .\ Lx .( Ly \ (*{\|dddd wdd wwdd wzdd zy\z$$,dd ,wdd ,wdd ,zdd +  !Dy!D  '"z  ' '"{  ' .\"| .("} \ (*}\~dddd wdd wwdd wzdd z{\|$$,dd ,edd ,dd +  " }"  & % '\#!~  ' SectionIII. '\#!  ' RecordKeeping(CurrentlyParticipatingFacilities) (\#!  (*\dddd edd edd }\~$$,dd ,wdd ,wdd ,zdd +  h$"h$"  '$t"  ' G=$t"   ?1.?G_1._ F<7$t"  ?1. ? F#%& 磣#& %DoestheFacilitymaintainthefollowingNPEcommodityrecords?(AgreementForm, $t" DeliveryReceipts,PaymentRecords,Inventoryforms/records,otherlettersandNPE %B# commodityprogramcorrespondence).(h&$  (*\dddd wdd wwdd wzdd z\$$,dd ,wdd ,wdd ,dd , dd ,dd ,dd +  t'%t'%  ''%  ' ''%  ' ''%  ' ''% 'Yes .\'% . ''%\ '  No(Ifno,pleaseindicatewhichrecordsarenotmaintainedandwhy)1'%'%  1*\dddd wdd wwdd wdd  dd dd dd \$$,dd ,wdd ,wdd ,zdd +  (&(&  'H)&  ' 'H)&  ' .\H)& .(H)& \ (*\dddd wdd wwdd wzdd z\$$,dd ,zdd +  T*'T*'  JE(%& & %(JEPARTB. 'y+!)  ' OBLIGATIONS/RESPONSIBILITIES  (+.)  (*b\dddd zdd z\$$,dd ,,dd ,dd ,zdd +  XX  'd  ' 'd  ' 'd  '  TheKansasDepartmentofSocialandRehabilitationServices(SRS)willrequestUnited d StatesDepartmentofAgricultureFoodstodistributetothisRecipientFacilityaccordingto 2  theagreementbetweenSRSandUSDA,andaccordingtothememorandumof X understandingbetweenSRSandtheKansasDepartmentonAging(KDOA).Inorderto & qualify,fullinformationconcerningtheFacilitywillbefurnishedtoSRSontheofficialstate  application/agreementform.SRSshalldetermineeligibilitybasedupontheinformation j  provided.RecipientFacilitiesmustmeetallapplicablestateand/orfederalregulations 8  priortoparticipating.ThegoverningbodyoftheFacility(Hereinafterreferredtoas ^  RecipientFacility)andtheFacilitysXJX%& supervisingProjectalsoagreestothetermsand ,   conditionsassetforthinthisagreement.#& %XXJ# 0&!   0 ' 9   ' F< 9    ?1?F_1_ E;6 9   ?1 ? E  TheFacilitymustmaintainanestablishedfeedingoperationonaregularbasisasan  9  integralpartofitsnormalactivities,andshallnotdiscriminateagainstanypersonreceiving _   foodbecauseofhis/herrace,ancestry,color,nationalorigin,sex,age,disability,religion -  orinabilityorunwillingnesstodonatetotheFacility.Facilitiesmustbeorganizedforthe   purposeofprovidingcontinuingwelfareservicesinthesameplacewithoutmarked q  change. 0&!?  0 '  ' F<   @2@F_2_ E;6  @2 @ E  TheRecipientFacilityunderstandsthatthedistributionofcommoditiesrequestedwillbe  subjecttotheavailabilityofthosecommodities. 0&!} 0 'E  ' F<E   @3@F_3_ E;6E  @3 @ E  TheRecipientFacilityagreesthatavailableUSDAFoodswillberequestedfromSRSonly E inquantitieswhichcanbeconsumedwithoutwasteandbasedoneitherthetotalnumber   ofeligiblesortheratesofallocationestablishedbySRSorUSDA.Itistheresponsibility ! oftheFacilitytodemonstratethatthefullvalueequivalenttotheUSDAcostofall W" commoditiesareusedsolelyforthebenefitoftheFacility. 0&!}%# 0 '$  ' F<%   @4@F_4_ E;6&  @4 @ E  SRSwillacceptUSDAfoodsattheStatecollectionpoint(s)andwillarrangefortheir ' deliverythroughouttheState.DeliveriestotheFacilitiesornearbypointswillbemadeat c( approximatelythirty(30)dayintervalsformostFacilitiesbuttheallocationperiodmaybe 1) subjecttochangeaccordingtothenumberofpersonsinvolved,becauseofgeographic W* locationoftheFacility,orduetospecialfoodoffers. 0&!%+ 0 '=,  ' F<=-   @5@F_5_ E;6=.  @5 @ E  FollowingeachdeliverytoaFacility,F&AFoodSales,Inc.oritssuccessor(theState =/ warehousecontractor)willbilltheFacilityssupervisingProjectatafixedratepercaseor c 0 baleoffooddelivered.Thischargeistopayadministrative,handling,storageand 11 transportationcostsofoperatingtheprogram.ThesupervisingProjectagreestopayin 2 fulltotheF&AFoodSales,Inc.oritssuccessorwithinthirty(30)daysafterthedateof u3 thedelivery.FailurebyanysupervisingProjecttomakepaymentwithinthirtydays  C4 followingthedateofthedeliverywillconstitutereasontosuspendtheprogramforsuch i!5 ProjectsFacility(ies)untilpaymentofthedelinquentaccountismadeinfull. 0&!7"6 0 '#O!7  ' F<#O!8   @6@F_6_ E;6#O!9  @6 @ E  USDAfoodsreceivedunderthisagreementwillbeusedsolelyinpreparedmealsforthe #O!: benefitofthosepersonsservedorassistedthroughtheNutritionProgramfortheElderly u$"; bytheRecipientFacility.USDAfoodswillnotbeotherwisedisposedoforusedfor C%"< demonstrations,tests,ortransferredtoanotherFacilityorprogramwithoutpriorwritten &#= approvalofSRS.UndernocircumstanceswillUSDAfoodsbesoldortradedforother &$> goodsorservices. 0&!'U%? 0 'd  ' F<d   @7@F_7_ E;6d  @7 @ E  Facilitiesforproperhandlingandstoringofcommoditiesrequestedandacceptedwillbe d providedbytheRecipientFacility.SRSandUSDAareauthorizedtoinspectatany 2 reasonabletimetheUSDAfoodsinstorageorthefacilitiesandwarehousesusedin X handlingorstorageofUSDAfoods.TheRecipientFacilityfurtheragreesto:maintain & properinventoryrecordsandcontrols,keepitsstoragefacilitiessanitary,freefromrodents,  birds,insects,andotheranimalinfestation,clean,dry,orderly,installthermometers, j  providesuitableventilation,providelocksforstorerooms,providespecifiedtemperatures 8   forcertaincommoditieswithintheirownbuildingsorincommercialcoldstorage,useall ^  itemsonthebasisoffirstin-firstout,andtakeotherstepsasmaybenecessaryinorder ,   tomaintainthefitnessforhumanconsumptionofUSDAcommodities. 0&!   0 'j    ' F<j      @8 @F_8_ E;6j     @8  @ E  TheRecipientFacilityandtheSupervisingProjectjointlyandseverelyassumeliabilityfor j   (1)alllossesordamagestoUSDAcommoditiescausedbyitsownfaultornegligence;and 8  (2)improperuseofUSDAcommodities.ClaimsarisingthereofmaybeleviedbySRS   againsttheRecipientFacilitytorecoverthemonetaryvalueofUSDAcommoditiessolost  |  ormisused.TheRecipientFacilityandsupervisingProjectwillimmediatelynotifySRSof J  (1)anylosses,(2)"out-of-condition"commoditiesreceivedorinstorageor(3)excess p  inventorieswhichcannotbeused,andwillawait/followdispositioninstructionsfromSRS. 0&!>  0 'V  ' F<V   "@9"@F_9_ E;6V  "@9 "@ E  ContainersreceivedwiththefoodsfromUSDAwillbedestroyedandwillnotbereusedor V sold. 0&!|$ 0 '  ' G=   $@10$@G_10_ F<7  $@10 $@ F  ProjectsthatemployfoodservicecompaniesforthefeedingoftheFacilitysrecipientswill   beeligibletoreceiveUSDAfoods.TheSupervisingProjectwillpresentthecontractto b! SRSforapprovalbeforetheProjectsFacilitycanbecertifiedaseligibletoreceiveUSDA 0" foods.Thetermsofthecontractmustbeineffectfornolongerthanoneyear,maybe V# extendedattheoptionofbothpartiesforfouradditionaloneyearperiodsandmaybe $$ terminatedforcausebyeitherpartyupon30daysnotice.Allstateandfederalregulations % regardingtheprocessingofUSDAfoodswillhavetobemetbeforeSRSwillapproveany h& foodservice/processingcontract. Donotunderanycircumstancesprovide 6' commoditiestoprocessorsorfoodservicecompanieswithoutpriorapprovalofthe \( SRSFoodDistribution Unit.(See2104fordetails.) Anycommoditiesreceivedbythe *) Facilityandmadeavailabletothefoodservicecompanyshallbeusedonlyforthebenefit * oftheFacilitiesfeedingoperationandshallbeutilizedthere.Thebooksandrecordsofthe n+ foodservicecompanypertainingtothefeedingoperationoftheFacilityshallbeavailable <, foraperiodofthree(3)yearsfromthecloseoftheFederalfiscalyeartowhichtheypertain b - forinspectionandauditbyrepresentativesofSRSandUSDA.AFoodServiceCompany 0. ContractAddendum(SeeExhibitF)mustbeexecutedbetweenthesupervisingProject / andthefoodservicecompanybeforesuchcompanymayagreetoprepareUSDAfood.  t0 ThisFoodServiceCompanyContractAddendummustbecompletedwithandbeattached !B1 totheapplication/agreementform.Theaddendumformprovidesdetailedbasic h" 2 requirementsforRecipientFacilitiesthatutilizefoodservicecompaniesinpreparingUSDA 6# 3 foods.AnewFoodServiceCompanyContractAddendumisrequiredforeachsubsequent $!4 certificationperiod. 0&!$z"5 0 'B  ' G=B   &@11&@G_11_ F<7B  &@11 &@ F  Recordspertainingtothereceiptanduseofcommoditieswillbekeptforaperiodofnot B  lessthanthreeyearsfromthecloseofthecurrentFederalFiscalYear.Reportswillbe '$: furnishedtoSRSasrequired. 0&!'%; 0 'N)&<  ' G=N)&=   ?1.?G_12_ F<7N)&>  ?1. ? F  TheRecipientFacilitywillpermitSRSand/orUSDApersonneltoinspectatanyreasonable N)&? timetheUSDAfoodsinstorage,orthefacilitiesorwarehouseusedinthehandlingor *'@ storageofUSDAfoods.TheRecipientFacilitywillalsomakeavailabletoSRSandto *(A USDApersonnelforexaminationandauditatanyreasonabletimeandplaceallaccounts +`)B andrecords,includingfinancialaccounts,pertinenttotheNutritionProgramfortheElderly ,.*C commodityprogram. 0&!T-*D 0 'd  ' G=d   *@13*@G_13_ F<7d  *@13 *@ F  TheRecipientFacilityagreestoreporttoSRSanycomplaintsofirregularitiesinconnection d withthereceiptanduseofUSDAcommodities. 0&!2 0 '  ' G=   ,@14,@G_14_ F<7  ,@14 ,@ F  TheRecipientFacilityherebyagreesthatitwillcomplywithTitleVIoftheCivilRightsAct   of1964(_P.L._Ԁ88-352),TitleIXoftheEducationAmendmentsof1972,Section504ofthe p  RehabilitationActof1973(_P.L._Ԁ93-112),AgeDiscriminationActof1975(_P.L._Ԁ94-135and >  allrequirementsimposedbytheregulationsoftheDepartmentofAgriculture(7CFRPart d   15),DepartmentofJustice(28CFRParts42and50)andFNSdirectivesorregulations 2  issuedpursuanttothatActandtheregulationstotheeffectthat,nopersonintheUnited   Statesshall,onthegroundofrace,ancestry,color,nationalorigin,age,sex,religionor  v disability,beexcludedfromparticipationin,bedeniedthebenefitsof,orbeotherwise  D subjecttodiscriminationunderanyprogramoractivity;andherebygivesassurancethat j   itwillimmediatelytakeanymeasuresnecessarytoeffectuatethisagreement. 8  Thisassuranceisgiveninconsiderationofandforthepurposeofobtaininganyandall  |  Federalfinancialassistance,grantsandloansofFederalfunds,reimbursable J  expenditures,grantordonationofFederalpropertyorthefurnishingofserviceswithout p  considerationoratanominalconsideration,orataconsiderationwhichisreducedforthe >  purposeofassistingtherecipient,orinrecognitionofthepublicinteresttobeservedby   suchsale,leaseorfurnishingofservicestotherecipient,oranyimprovementsmadewith  FederalfinancialassistanceextendedtotheprogramapplicantbytheDepartment. P ThisincludesanyFederalagreement,arrangement,orothercontractwhichhasasone D ofitspurposestheprovisionofassistancesuchasfood,cashassistanceforpurchaseor  rentaloffoodserviceequipmentoranyotherfinancialassistanceextendedinrelianceon  therepresentationsandagreementsmadeinthisassurance. V Byacceptingthisassurance,theRecipientFacilityagreestopermiteffectiveenforcement J! ofTitleVIandpermitauthorizedDistributingAgencyandUSDApersonnelduringnormal " workinghourstoreviewasneededtoascertaincompliancewithTitleVI.Ifthereareany # violationsofthisassurance,theDepartmentofAgriculture,FoodandNutritionService, \$ shallhavetherighttoseekjudicialenforcementofthisassurance.Thisassuranceis *% bindingontheRecipientFacility,itssuccessors,transferees,andassigneesaslongasit P& receivesassistanceorretainspossessionofanyassistancefromtheDepartment.The ' personorpersonswhosesignaturesappearbelowareauthorizedtosignthisassurance ( onthebehalfoftheprogramapplicant. 0&!b) 0 '* *  ' G=* +   .@15.@G_15_ F<7* ,  .@15 .@ F  Notwithstandinganyotherprovisions,SRSmayimmediatelyterminatethisagreement * - uponreceiptofevidenceof(1)noncomplianceor(2)lossoffundingsource.EitherSRS  . ortheRecipientFacilitymayterminatethisagreementbygivingthirty(30)daysnoticein !n/ writingtotheotherparty.Subjectto(1)suchnoticeofterminationor(2)upon "< 0 non-approvalofasubsequentapplication,theRecipientFacilityagreestocomplywiththe b# !1 instructionsfromSRStoeither(1)utilizeallremaininginventoriesofUSDAcommodities 0$!2 inaccordancewiththeprovisionsofthisagreement,or(2)transfertheremaining $"3 inventoriestoanothereligiblerecipientagencydesignatedbySRS.TheRecipientFacility %t#4 ortheFacilityssupervisingProjectagreesto(1)bearallcostsincurredrelatingtosuch &B$5 transferand(2)transmitsuchreportsasmayberequiredbytheStateAgencytorecord h'%6 finaldisposition. 0&!6(%7 0 ')N'8  ' ')N'9  ' ')N': ' ')N'; ' '+(<  ' '+(=  ' '+(> ' '+(? ' ',.*@  ' ',.*A  ' ',.*B ' ',.*C ' '-+D  ' '-+E  ' '-+F '(-+G   (*\dddd ,dd ,dd zdd zb\$$,dd ,zdd +  XX  JE(%& & %(JEPARTC. '}%  ' AGREEMENTCOMPLIANCE (2  (*\dddd zdd z\$$,X dd +  >>   Iherebycertifythatthecontentsofthisagreementhavebeencarefullyreadbythepersonorpersons  havingcontrolovertheconsummationofagreementsforthisFacility,thatalltheinformationinthisform p iscompleteandcorrecttothebestofmyknowledge,andtheFacilitywillacceptallobligationsas > containedherein.ThisagreementreplacesanyexistingagreementsbetweenSRSandtheRecipient d  Facility.Upontheexecutionofthisagreement,anysuchprioragreementsshallbeconsiderednulland 2  void.1'%    1*l\ddX dd X \$$l, dd ,dd , dd +       'p    ' 'p   ' 'p   ' '  ' '  ' '  '  %& NameofFacilityRepresentative P  (Whofilledoutthisform)#& %#Ԁ 0&!     0 'P  '  %& Signature#& %# 0&!P    0 '{#  ' '{#  ' '{#  '  %& TitleofFacilityRepresentative#& %# 0&!   0 ' '  %& Date#& %x# 7\&!   7 '[\ ' '[ ' '[ '  %& NameofFacilitysSupervisingProject s Representative(Pleasetypeorprint)#& %v# 0&!.   0 's  '  %& Signature#& %~# 0&!s!   0 '" ' '# ' '$ '  %& TitleofFacilitysSupervisingProject R% Representative  &  0&!p'   0 'R( '  Date1'%R)     1*\d d dd dd  dd \$$,X dd +  %h)h %,8,($*  (#8,,o#*l\ddX dd X \$$l,X dd +  t*t   FORAGENCYUSEONLY 1'%0+   1*l\ddX dd X \$$l,dd , dd ,dd ,dd ,dd ,` dd ,dd +  (+(  '4,  ' '4- 'InitialAgreement '4. ' '4/ ' '40 'Redetermination '41  '(42  (*\dddd  dd dd dd dd ` dd ` dd \$$,dd ,dd ,dd , dd +  ,2, DateAgreementReceived 'K4 ' '5 ' '6  'DETERMINATIONPERIOD(K8  (*\dddd dd dd  dd \$$,dd ,dd ,dd ,dd ,1 dd +  C8C DateAgreementProcessed '9 ' ': ' '; 'From: '< ' '= ' '[!> ' '[!?  ' '[!@  'Thru: '[!A '([!B   (*\dddd dd dd dd 1 dd 1 \$$,X dd +  S"BS" Disposition(checkone)("_ C  (*l\ddX dd X \$$l,dd ,dd , dd , dd +  #W!C#W! Approved '$!D ' '$!E ' '$!F ' '$!G 'Denied * o%#H *  * 'o%#I0 ' 'o%#J '  SignatureofEligibilityWorker1'%o%#K     1*\dddd dd  dd dd \$$, dd ,dd , dd +  g&$Kg&$  * DenialCommentsBelow: '&s$L ' '&s$M ' '&s$N ' ''(%O  ' ''(%P '  Date1'%'(%Q     1