MCPS Form 240-54 Monthly Invoice Child and Adult CareFood

Provider Monthly Invoice
Vendor # Child and Adult Care Food Program
Division of Food and Nutrition Services
MONTGOMERY COUNTY PUBLIC SCHOOLS
8401 Turkey Thicket Drive
Gaithersburg, Maryland 20879
Address Home Phone -
-
Month Year Children Claimed : Day Care Own I CERTIFY that the information submitted is accurate in all respects, and that I understand this information is given in
connection with the receipt of federal funds, and that deliberate misrepresentation may result in state or federal prosecution.
Child’s Name
Hours and Days of Care
Age
Child’s Name
Hours and Days of Care
Age
Child’s Name
Hours and Days of Care
Age
Child’s Name
Hours and Days of Care
Age
Child’s Name
Hours and Days of Care
Age
Child’s Name
Hours and Days of Care
Age
MCPS Form 240-54,
Rev. 5/15
Meals
1
2
3
4
5
6
7
8
9
Signature, Provider
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Meals Total
B
AM
L
B
AM
L
PM
PM
S
S
B
/
Date
/
TO BE FILLED OUT BY MCPS
AM
L
PM
S
Attendance
Meals
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Meals Total
B
B
AM
AM
L
L
PM
PM
S
S
B
AM
L
PM
S
B
AM
L
PM
S
B
AM
L
PM
S
B
AM
L
PM
S
B
AM
L
PM
S
Attendance
Meals
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Meals Total
B
B
AM
AM
L
L
PM
PM
S
S
Attendance
Meals
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Meals Total
B
B
AM
AM
L
L
PM
PM
S
S
Attendance
Meals
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Meals Total
B
B
AM
AM
L
L
PM
PM
S
S
Attendance
Meals
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Meals Total
B
B
AM
AM
L
L
PM
S
Attendance
PM
S
B
DISTRIBUTION: COPY 1&2/MCPS Division of Food and Nutrition Services; COPY 3/Provider
AM
L
GRAND TOTALS PM
S
TO BE FILLED OUT BY MCPS TOTALS