Form Doh-3688 - Income Eligibility Form - New York

ADVERTISEMENT

Income Eligibility Form
NEW YORK STATE DEPARTMENT OF HEALTH
for Child Care Centers
Child and Adult Care Food Program
See INSTRUCTIONS on reverse.
CHILD CARE CENTER NAME
____________________________________________________________________________________________________________________________________________________________________________
Print the name of the child(ren) enrolled in this child care center
1.
2.
3.
____________________________________________________________
________________________________________________________________
____________________________________________________________
DIRECTIONS
Complete SECTION A if anyone in your household
Complete SECTION B if no one in your household participates in SNAP,
1. Participates in the Supplemental Nutrition Assistance Program (SNAP)
receives TANF, participates in FDPIR or if none of the children enrolled in
2. Receives Temporary Assistance to Needy Families (TANF)
the child care center is a foster child.
3. Participates in the Food Distribution Program on Indian Reservations
(FDPIR) OR
4. Is a foster child
SECTION A
SECTION B
SNAP Case #
List all household members below. Include yourself and all adults and
_____________________________________________________________________________________
children NOT listed above, even if they do not receive income. Then list all
TANF #
income received last month in your household in the column to the right.
_____________________________________________________________________________________________
Gross income includes: earnings from work, pensions, retirement, Social
FDPIR #
Security, child support, foster child's personal income and any other
____________________________________________________________________________________________
sources of income.
Names of
__________________________________________________________________________________
HOUSEHOLD MEMBER NAME
MONTHLY GROSS SALARY
Foster Children
__________________________________________________________________________________
1.
$
__________________________________________________________
___________________________________
An adult household member must sign the application before it can
2.
$
__________________________________________________________
___________________________________
be approved. After reading the following statement and the statement on
the back, sign below.
3.
$
__________________________________________________________
___________________________________
I certify that the above information is true. I understand that the center
4.
$
__________________________________________________________
___________________________________
will get Federal funds based on the information I give.
5.
$
__________________________________________________________
___________________________________
Signature
__________________________________________________________________________________________
6.
$
__________________________________________________________
___________________________________
Date
7.
$
__________________________________
__________________________________________________________
___________________________________
An adult household member must sign the application before it can
FOR SPONSOR USE ONLY
be approved. After reading the following statement and the statement on
the back, sign below.
CACFP Agreement #____________________
Total Number of Household Members__________
I certify that the above information is true and that all income is reported.
(INCLUDING FOSTER CHILDREN, IF APPLICABLE)
I understand that the center will get Federal funds based on the
information I give.
Total Household Income $____________________
Free________________ Reduced________________ Paid________________
Signature
__________________________________________________________________________________________
Date of Determination____________________
Print Name
Signature of
_______________________________________________________________________________________
Center Staff______________________________________________________________
LAST FOUR (4) DIGITS OF
SOCIAL SECURITY NUMBER
DATE
USDA is an equal opportunity provider and employer.
DOH-3688 (6/14) Page 1 of 2

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Doh-3688 - Income Eligibility Form For Child Care Centers Form Doh-3688 - Income Eligibility Form For Child Care Centers Legal
Form Doh 3122 - Assisted Living Residence Medical Evaluation Form - New York Form Doh 3122 - Assisted Living Residence Medical Evaluation Form - New York Legal
Form Doh-61h - Multiple Victim Injury Report Form - New York State Department Of Health Form Doh-61h - Multiple Victim Injury Report Form - New York State Department Of Health Legal
Form Doh-4065 - Adoption Information Registry Birth Parent Registration Form - New York State Department Of Health Form Doh-4065 - Adoption Information Registry Birth Parent Registration Form - New York State Department Of Health Legal
Form Doh-4212 - Emergency Pesticide Application Notification Exemption Reporting Form - New York State Department Of Health Form Doh-4212 - Emergency Pesticide Application Notification Exemption Reporting Form - New York State Department Of Health Legal
Form Doh-743 - Instructor Information Sheet - New York State Department Of Health Form Doh-743 - Instructor Information Sheet - New York State Department Of Health Legal
Form It-150 - Resident Income Tax Return Form - New York State Department Of Taxation And Finance - New York Form It-150 - Resident Income Tax Return Form - New York State Department Of Taxation And Finance - New York Financial
Form Tt-102 - New York State Resident Affidavit Form - New York State Department Of Taxation And Finance - New York Form Tt-102 - New York State Resident Affidavit Form - New York State Department Of Taxation And Finance - New York Legal
Form Nyc-210 - Claim For New York City School Tax Credit Form - New York State Department Of Taxation And Finance Form Nyc-210 - Claim For New York City School Tax Credit Form - New York State Department Of Taxation And Finance Financial
Form St-101 - New York State And Local Annual Sales And Use Tax Return Form - New York State Department Of Taxation And Finance Form St-101 - New York State And Local Annual Sales And Use Tax Return Form - New York State Department Of Taxation And Finance Financial

Related Categories

Parent category: Legal
Download
Go
Page of 2