VIRGINIA CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM FOR CHILD CARE CENTERS and FAMILY DAY HOMES
All Household Members
NAMES OF ALL HOUSEHOLD MEMBERS
[Adults and Children]
SNAP, TANF or FDPIR CASE #
Skip to Part 6 if you list a SNAP,
Skip to Part 6 if all are
First, Middle Initial, Last
TANF or FDPIR case number
MUST BE SEVEN (7) DIGITS
4 Homeless, Migrant, Runaway
If any child you are applying for is homeless, migrant, or a runaway, check the appropriate box and call
your School Homeless Liaison, Migrant Coordinator.
5 Total Household Gross Income (before deductions). You must tell us how much and how often.
GROSS INCOME AND HOW OFTEN IT IS RECEIVED (Example: $100/month, $100/twice a month, $100/every other week, $100/week)
Pensions, Retirement, Social
(LIST ALL HOUSEHOLD
Earnings From Work
Unemployment, SSI, etc. (All
MEMBERS WITH INCOME)
Signature and Social Security Number (Adult must sign)
X X X
An adult household member must sign the application. If Part 5 is completed or if zero income
_ _ _ - _ _ - _ _ _ _
I do not have a social
is listed, the adult signing the form must also list the last four digits of his or her social
Social Security Number
security number or mark the I do not have a social security number box.
I certify that all information on this form is true and that all income is reported. I understand that the center or day care home will get Federal funds based on the information I
give. I understand that CACFP officials may verify the information. I understand that if I purposely give false information, the participant receiving meals may lose the meal
benefits, and I may be prosecuted.
Printed Name of Adult Household Member
Signature of Adult Household Member
7 Contact Information (Optional)
Work Telephone Number (Include Area Code)
Home Telephone Number (Include Area Code)
Home Address (Number, Street, City, State, Zip Code)
Optional - Sharing Information with Virginia’s Health Insurance Program for Children (FAMIS)
May we share your information on this application with the FAMIS , the complete health insurance program for every child in Virginia ? If yes , do not sign below.
No, I do not want my information from this application
shared with the FAMIS.
PRIVACY ACT STATEMENT: The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or
reduced-price meals. You must include the last four digits of your social security number of the adult household member who signs the application. The social security number is not required when you apply on behalf of a foster child or
you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program, or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for
your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced-price meals, and for
administration and enforcement of the Child and Adult Care Food Program. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs,
auditors for program reviews, and law enforcement officials to help them look into violations of program rules.
NON-DISCRIMINATION STATEMENT: The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex,
gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program or activity
conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination
Complaint Form, found online at , or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form.
Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at
email@example.com. Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint please contact USDA through the Federal Relay Service at (800) 877-8339 or (800)
845-6136 (in Spanish). USDA is an equal opportunity provider and employer.
CHILD CARE REPRESENTATIVE USE ONLY - ELIGIBILITY DETERMINATION - COMPLETE SECTIONS A and B BELOW
Convert income only if different
Annual Income Conversion: Weekly X 52
Every 2 Weeks X 26
Twice a Month X 24
Once a Month X 12
frequencies of pay are reported.
TOTAL INCOME $______________ Per:
Every 2 Weeks
Twice a Month
SNAP or TANF
income too high
Signature of Determining Official:
Virginia Department of Health
Division of Community Nutrition
Revised July 1, 2014