1-Appendix B FSMC Certification of Acknowledgement.pdf
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- Attached to
- Jefferson Academy- Food Service Management
- Solicitation number
- RA26-146
- Issued by
- Davis County, Utah
About this file
This document is an FSMC (Food Service Management Company) Certification of Acknowledgement form for Jefferson Academy in Utah, serving as a mandatory compliance certification required as part of the food service management contract procurement process. The FSMC Authorized Representative must certify understanding and compliance with multiple contract requirements, including adherence to the 21-day initial menu without modification, compliance with current meal standards and Local Wellness Policy, and commitment to follow all applicable federal and state regulations governing Child Nutrition (CN) programs administered by the state agency. The form requires the authorized representative to initial thirteen separate certification statements and provide their printed name, title, and signature, with a question cutoff date of June 5, 2026, and proposal submission deadline of June 29, 2026 at 3:00 PM MDT to Nicole Jones at Jefferson Academy's address in Kaysville, Utah.
The certification form establishes critical governance and operational requirements, including verification that neither the FSMC nor its principals are debarred or have criminal backgrounds affecting CN program involvement, that FSMC employees will receive training on the school food authority's (SFA) Code of Conduct, that all food service employees meet Professional Standards requirements, and that the SFA retains legal responsibility for the non-profit school food service program with access to all vendor contracts and documentation. The FSMC explicitly certifies it will not control CN program accounts, signature authority, financial responsibility, student information systems, or student eligibility determinations, and affirms compliance with environmental regulations under the Clean Air Act and Federal Water Pollution Control Act. The signatory attests under penalty of perjury that all information is true and correct and commits to immediate reporting of any changes, while acknowledging USDA non-discrimination policies.
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Appendix B
FSMC Certification of Acknowledgement
Initial below next to each statement certifying that you have read and fully understand the contents of this contract.
A. I certify that I, ____________________, the FSMC Authorized Representative, on behalf of the FSMC, have read and fully understand the contents of this contract.
Initial Here: __________
B. I certify that I, ____________________, nor any of the employees of the FSMC, have not received any solicitations from any SFA employee. In addition, I certify that no gifts, donations, or anything of monetary value (i.e., golf outings, meals, etc.) have been provided.
Initial Here: __________
C. I certify that employees of the FSMC will be trained to understand and comply with all necessary trainings including the current written Code of Conduct authored by the SFA.
Initial Here: __________
D. I certify that all the FSMC food service employees meet the minimum Professional Standards requirements.
Initial Here: __________
E. I certify that the SFA will be legally responsible for the conduct of the non-profit school food service program, and shall have access to all necessary documents, which will be maintained onsite, including but not limited to all contracts with vendors so that they may supervise the food service operations in such manner as will ensure compliance with the rules and regulations of PDE and the USDA regarding each of the CN programs covered by this contract.
Initial Here: __________
F. I certify that the FSMC will not have control of the CN programs’ non-profit school food service account, signature authority, and overall financial responsibility for the CN programs.
This includes access to the student information system and/or food service system.
Initial Here: __________
1 Revised: 04/24/2026
G. I certify that the SFA will be responsible for determining student eligibility for all applicable programs and that the FSMC will have no involvement in the process.
Initial Here: __________
H. I certify that the FSMC will follow the 21-day menu for the first 21-days of service, without change.
Initial Here: __________
I. I certify that all food will be in compliance with the current meal standards and Local Wellness Policy.
Initial Here: __________
J. I certify that the FSMC will comply with all applicable standards, orders, or requirements issued under the Clean Air Act and the Federal Water Pollution Control Act and will report violations to the Federal awarding agency and the Regional Office of the Environmental Protection Agency.
Initial Here: __________
K. I hereby certify that neither the FSMC nor its principals/authorized representatives is presently debarred, suspended, proposed for debarment, declared ineligible, disqualified, or voluntarily excluded from participation in this transaction by any Federal/State department or agency.
Initial Here: __________
L. I further certify that neither the FSMC nor any of its principals/authorized representatives has a reported criminal background that would affect the involvement in CN programs.
Initial Here: __________
M. I certify that the FSMC is not a paid consultant or contractor with the SFA in any other capacity than for this contract.
Initial Here: __________
2 Revised: 04/24/2026
I certify under penalty of perjury that the information on these forms is true and correct, and that I will immediately report to the state agency any changes that occur to the information submitted. I understand that this information is being given in connection with receipt of federal funds. The state agency may verify information; and the deliberate misrepresentation of information will subject me to prosecution under applicable federal and state criminal statutes.
On behalf of the SFA I hereby agree to comply with all state and federal laws and regulations governing the CN programs administered by the state agency. In accordance with Federal law and USDA policy, the SFA does not discriminate on the bases of 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 the USDA. I will ensure that all monthly claims for reimbursement are true and correct and that records are available to support these claims.
Printed Name of FSMC Authorized Representative
FSMC Authorized Representative Title
FSMC Authorized Representative Signature
3 Revised: 04/24/2026
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