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1 | Field Seq. | Position From | Position To | Description | Field Size | Field Type | Required | Notes | ||||||||||||||||||
2 | 1 | 1 | 3 | Upload Form ID | 3 | N(3,0) | Y | Value = 627 for every record | ||||||||||||||||||
3 | 2 | 4 | 9 | Serial Number | 6 | N(6,0) | Y | Sequential Record Number (1, 2, 3, etc.) | ||||||||||||||||||
4 | 3 | 10 | 17 | Process Date | 8 | N(8,0) | N | Leave Blank | ||||||||||||||||||
5 | 4 | 18 | 23 | BLANK | 6 | C(6) | N | Leave Blank | ||||||||||||||||||
6 | 5 | 24 | 87 | Sponsor Name | 64 | C(64) | Y | Sponsor Legal Name | ||||||||||||||||||
7 | 6 | 88 | 103 | Agreement Number | 16 | C(16) | Y | Sponsor Identification Number; zero fill from left e.g. 01234 | ||||||||||||||||||
8 | 7 | 104 | 105 | Claim Month | 2 | N(2,0) | Y | Enter the month the claim is being submitted for: Calendar month number (01, 02, …. 11, 12) | ||||||||||||||||||
9 | 8 | 106 | 109 | Claim Year | 4 | N(4,0) | Y | Enter the year the claim is being submitted for: | ||||||||||||||||||
10 | 9 | 110 | 141 | Provider First Name | 32 | C(32) | Y | Site Name after comma | ||||||||||||||||||
11 | 10 | 142 | 173 | Provider Last Name | 32 | C(32) | Y | Site Name before comma | ||||||||||||||||||
12 | 11 | 174 | 189 | License Number | 16 | C(16) | N | Facility License Number | ||||||||||||||||||
13 | 12 | 190 | 205 | Provider ID | 16 | N(16) | Y | Site Identification Number | ||||||||||||||||||
14 | 13 | 206 | 221 | Blank | 16 | C(16) | N | Leave Blank | ||||||||||||||||||
15 | 14 | 222 | 228 | Blank | 7 | N(7,0) | N | Leave Blank | ||||||||||||||||||
16 | 15 | 229 | 235 | Blank | 7 | N(7,0) | N | Leave Blank | ||||||||||||||||||
17 | 16 | 236 | 242 | Blank | 7 | N(7,0) | N | Leave Blank | ||||||||||||||||||
18 | 17 | 243 | 249 | Blank | 7 | N(7,0) | N | Leave Blank | ||||||||||||||||||
19 | 18 | 250 | 256 | Number of Days Meals Served Tier I | 7 | N(7,0) | N | If claim is Tier I, number of days with mealattendace. If Tier II high, mixed or low, leave blank | ||||||||||||||||||
20 | 19 | 257 | 263 | Number of Days Meals Served Tier II High | 7 | N(7,0) | N | If claim is Tier II High or Mixed, number of days with mealattendance for children that are foster children OR in a household with Tier I income form. If Tier I or Tier II low, leave blank | ||||||||||||||||||
21 | 20 | 264 | 270 | Number of Days Meals Served Tier II Low | 7 | N(7,0) | N | If Tier II Mixed or Low, the number of days with mealattendance for a child that is not foster or in a household without an income form or in a household with an income form with Tier II. If Tier I or Tier II High, leave blank | ||||||||||||||||||
22 | 21 | 271 | 277 | Blank | 7 | N(7,0) | N | Leave Blank | ||||||||||||||||||
23 | 22 | 278 | 284 | Blank | 7 | N(7,0) | N | Leave Blank | ||||||||||||||||||
24 | 23 | 285 | 291 | Blank | 7 | N(7,0) | N | Leave Blank | ||||||||||||||||||
25 | 24 | 292 | 298 | Blank | 7 | N(7,0) | N | Leave Blank | ||||||||||||||||||
26 | 25 | 299 | 305 | Blank | 7 | N(7,0) | N | Leave Blank | ||||||||||||||||||
27 | 26 | 306 | 312 | Breakfast Tier I Meals Served | 7 | N(7,0) | N | If claim is Tier I, then number of claimable Tier I breakfast, else blank | ||||||||||||||||||
28 | 27 | 313 | 319 | Breakfast Tier II High Meals Served | 7 | N(7,0) | N | If claim is Tier II High or Tier II mixed, then number of claimable Tier I breakfast, else blank | ||||||||||||||||||
29 | 28 | 320 | 326 | Breakfast Tier II Low Meals Served | 7 | N(7,0) | N | If claim is Tier II mixed or Tier II low, then number of claimable Tier II breakfast, else blank | ||||||||||||||||||
30 | 29 | 327 | 333 | AM Snack Tier I Meals Served | 7 | N(7,0) | N | If claim is Tier I, then number of Tier I AM Snack, else blank | ||||||||||||||||||
31 | 30 | 334 | 340 | AM Snack Tier II High Meals Served | 7 | N(7,0) | N | If claim is Tier II High or Tier II mixed, then number of Tier I AM Snack, else blank | ||||||||||||||||||
32 | 31 | 341 | 347 | AM Snack Tier II Low Meals Served | 7 | N(7,0) | N | If claim is Tier II mixed or Tier II low, then number of Tier II AM Snack, else blank | ||||||||||||||||||
33 | 32 | 348 | 354 | Lunch Tier I Meals Served | 7 | N(7,0) | N | If claim is Tier I, then number of Tier I lunch, else blank | ||||||||||||||||||
34 | 33 | 355 | 361 | Lunch Tier II High Meals Served | 7 | N(7,0) | N | If claim is Tier II High or Tier II mixed, then number of Tier I lunch, else blank | ||||||||||||||||||
35 | 34 | 362 | 368 | Lunch Tier II Low Meals Served | 7 | N(7,0) | N | If claim is Tier II mixed or Tier II low, then number of Tier II lunch, else blank | ||||||||||||||||||
36 | 35 | 369 | 375 | PM Snack Tier I Meals Served | 7 | N(7,0) | N | If claim is Tier I, then number of Tier I PM snack, else blank | ||||||||||||||||||
37 | 36 | 376 | 382 | PM Snack Tier II High Meals Served | 7 | N(7,0) | N | If claim is Tier II High or Tier II mixed, then number of Tier I PM snack, else blank | ||||||||||||||||||
38 | 37 | 383 | 389 | PM Snack Tier II Low Meals Served | 7 | N(7,0) | N | If claim is Tier II mixed or Tier II low, then number of Tier II PM snack, else blank | ||||||||||||||||||
39 | 38 | 390 | 396 | Supper Tier I Meals Served | 7 | N(7,0) | N | If claim is Tier I, then number of Tier I supper, else blank | ||||||||||||||||||
40 | 39 | 397 | 403 | Supper Tier II High Meals Served | 7 | N(7,0) | N | If claim is Tier II High or Tier II mixed, then number of Tier I supper, else blank | ||||||||||||||||||
41 | 40 | 404 | 410 | Supper Tier II Low Meals Served | 7 | N(7,0) | N | If claim is Tier II mixed or Tier II low, then number of Tier II supper, else blank | ||||||||||||||||||
42 | 41 | 411 | 417 | Evening Snack Tier I Meals Served | 7 | N(7,0) | N | If claim is Tier I, then number of Tier I Evening Snack, else blank | ||||||||||||||||||
43 | 42 | 418 | 424 | Evening Snack Tier II High Meals Served | 7 | N(7,0) | N | If claim is Tier II High or Tier II mixed, then number of Tier I Evening Snack, else blank | ||||||||||||||||||
44 | 43 | 425 | 431 | Evening Snack Tier II Low Meals Served | 7 | N(7,0) | N | If claim is Tier II mixed or Tier II low, then number of Tier II Evening Snack, else blank | ||||||||||||||||||
45 | 44 | 432 | 443 | Blank | 12 | N(10,2) | N | Leave Blank | ||||||||||||||||||
46 | 45 | 444 | 450 | Participants Enrolled Tier I | 7 | N(7,0) | N | If claim is Tier I, then number of participants that are not inactive with enrollment forms that are valid for at least one day for the claim month, else blank | ||||||||||||||||||
47 | 46 | 451 | 457 | Participants Enrolled Tier II High | 7 | N(7,0) | N | If claim is Tier II High or Tier II mixed, then the number of participants that are not inacive with enrollment forms that are valid for at elast one day of the claim month and either a foster child or in a household with a Tier I income form, else blank | ||||||||||||||||||
48 | 47 | 458 | 464 | Participants Enrolled Tier II Low | 7 | N(7,0) | N | If claim is Tier II High or Tier II mixed, then the number of participants that are not inacive with enrollment forms that are valid for at elast one day of the claim month and not foster children and in a household without an income form or with an income form that is Tier II, else blank | ||||||||||||||||||
49 | 48 | 465 | 471 | Blank | 7 | N(7,0) | N | Leave Blank | ||||||||||||||||||
50 | 49 | 472 | 478 | Total Attendance Tier I | 7 | N(7,0) | N | If claim is Tier I, then it is the sum of the dailyattendance for the month. If claim is Tier II high, mixed or low, leave blank | ||||||||||||||||||
51 | 50 | 479 | 485 | Total Attendance Tier II High | 7 | N(7,0) | N | If the claim is Tier II high or mixed, total of dailyattendance for children that are foster children OR in a household with Tier I income form. If Tier I or Tier II low, leave blank | ||||||||||||||||||
52 | 51 | 486 | 492 | Total Attendance Tier II Low | 7 | N(7,0) | N | If the claim is Tier II mixed or Tier II low, total of dailyattendance for a child that is not foster or in a household without an income form or in a household with an income form with Tier II. If claim is Tier I or Tier II high, leave blank | ||||||||||||||||||
53 | 52 | 493 | 499 | Blank | 7 | N(7,0) | N | Leave Blank | ||||||||||||||||||
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