Sponsor name:
Sponsor number:

Description of the anticipated capital expenditure (Refer to paragraph 15, “Equipment and other capital expenditures,” of the applicable Office of Management and Budget (OMB) Circulars A-87 or A-122)

Acquisition cost of the anticipated capital expenditure (“Acquisition cost” means the cost of the asset including the cost to put it in place. For example, the net invoice price of the equipment, including the cost of any modifications, attachments or auxiliary apparatus necessary to make it usable for the purchase for which it was acquired. Ancillary charges, such as taxes, duty, protective in transit insurance, freight, and installation may be included in, or excluded from the acquisition cost in accordance with the non-profit organization’s regular accounting practices.)

Please read and check the box next to each statement

I certify that the above referenced capital expenditure is necessary and reasonable for proper and efficient performance and administration of the Child Nutrition Program.

I certify that the above referenced capital expenditure is allocable to the federal award. A cost is allocable to a particular cost objective if the goods or services involved are chargeable or assignable in accordance with relative benefits received.

I certify that the above referenced capital expenditure is accorded consistent treatment. A cost may not be assigned to a federal award as a direct cost if any other cost incurred for the same purpose in like circumstances has been allocated as an indirect cost.

I certify that the above referenced capital expenditure is not included as a cost or used to meet cost sharing or matching requirements of any other federal award.

I certify that the above referenced capital expenditure is the net of all applicable credits.

Sponsor representative (print full name
Signature	Date:
E-mail address	Phone number

CSDE Use Only

Approved by:	Date:

Resources

7 CFR 200: Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards:
https://www.gpo.gov/fdsys/pkg/FR-2013-12-26/pdf/2013-30465.pdf

7 CFR 210: National School Lunch Program:
https://www.ecfr.gov/cgi-bin/text-idx?SID=4c211a738d6109939c6054a6286ac109&mc=true&node=pt7.4.210&rgn=div5s

Capital Expenditure Approved List for School Food Authority Equipment Purchases (CSDE): http://portal.ct.gov/-/media/SDE/Nutrition/NSLP/Forms/Equipment/EquipmentList.pdf

Equipment Purchase Approval Request Form (CSDE):
https://portal.ct.gov/-/media/SDE/Nutrition/NSLP/Forms/Equipment/EquipmentForm.doc

Equipment Purchase Prior Approval Process (CSDE):
https://portal.ct.gov/-/media/SDE/Nutrition/NSLP/Forms/Equipment/EquipmentApprovalpdf

OMB Circular A-87 Revised: Cost Principles for State, Local, and Indian Tribal Governments: https://obamawhitehouse.archives.gov/omb/circulars_a087_2004/

OMB Circular A-122 Revised: Cost Principles for Non-Profit Organizations: https://obamawhitehouse.archives.gov/omb/circulars_a122_2004/

USDA Memo SP 39-2016: State Agency Prior Approval Process for School Food Authority (SFA) Equipment Purchases:
https://fns-prod.azureedge.net/sites/default/files/cn/SP39_CACFP11_SFSP13_2016os.pdf

For information on the school nutrition programs, visit the CSDE’s School Nutrition Programs webpage or contact the school nutrition programs staff in the CSDE Bureau of Health/Nutrition, Family Services and Adult Education, 450 Columbus Boulevard, Suite 504, Hartford, CT 06103-1841. This handout is available at http://portal.ct.gov/-/media/SDE/Nutrition/NSLP/Forms/Equipment/EquipmentForm.doc.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: How to File a Complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. This institution is an equal opportunity provider.	The Connecticut State Department of Education is committed to a policy of equal opportunity/affirmative action for all qualified persons. The Connecticut Department of Education does not discriminate in any employment practice, education program, or educational activity on the basis of age, ancestry, color, criminal record (in state employment and licensing), gender identity or expression, genetic information, intellectual disability, learning disability, marital status, mental disability (past or present), national origin, physical disability (including blindness), race, religious creed, retaliation for previously opposed discrimination or coercion, sex (pregnancy or sexual harassment), sexual orientation, veteran status or workplace hazards to reproductive systems, unless there is a bona fide occupational qualification excluding persons in any of the aforementioned protected classes. Inquiries regarding the Connecticut State Department of Education’s nondiscrimination policies should be directed to: Levy Gillespie, Equal Employment Opportunity Director/Americans with Disabilities Coordinator (ADA), Connecticut State Department of Education, 450 Columbus Boulevard, Suite 607, Hartford, CT 06103, 860-807-2071, levy.gillespie@ct.gov.