Form Doh-3688 - Income Eligibility Form - New York (Page 2 of 2) in pdf

Privacy Act Statement: The Richard B. Russell National School Lunch Act requires the information on this form. You do not have to give the

information, but if you do not, we cannot approve the participant for free or reduced-price meals. You must include the last four digits of the Social

Security Number of the adult household member who signs the form. The Social Security Number is not required when you: apply on behalf of a foster

child; provide a SNAP, TANF or FDPIR number; or when you indicate that the adult household member signing the form does not have a Social Security

Number. We will use your information to determine if the center is eligible for free or reduced-price meal reimbursement and for administration and

enforcement of the Program.

INSTRUCTIONS FOR COMPLETING DOH-3688

Definition of Income

Income means income before deductions for income taxes, social security taxes, insurance premiums, charitable contributions, and bonds, etc. It includes

the following: (1) monetary compensation for services, including wages, salary, commissions or fees; (2) net income from non-farm self-employment; (3)

net income from farm self-employment; (4) Social Security payments; (5) dividends or interest on savings or bonds, income from estates or trusts or net

rental income; (6) unemployment compensation; (7) government civilian employee or military retirement, or pensions or veteran’s payments; (8) private

pensions or annuities; (9) alimony or child support payments; (10) regular contributions from persons not living in the household; (11) net royalties; (12)

military benefits received in cash, such as housing allowance except if you are in the Military Housing Privatization Initiative; and (13) any other cash

income.

Definition of Household

Household means family as defined in Section 226.2. Family means a group of related or non-related individuals who are not residents of an institution

or boarding house, but who are living as one economic unit.

INSTRUCTIONS FOR PARENTS OR GUARDIANS

Write in the name of the child care center in the space provided.

Print the name of each child in your household who attends this child care center.

Section A: If anyone in your household participates in the Supplemental Nutrition Assistance Program (SNAP), receives Temporary Assistance for Needy

Families (TANF) or participates in the Food Distribution Program on Indian Reservations (FDPIR), complete Section A only. Write down the SNAP, TANF

or FDPIR number (do not use your ACS or DSS child care subsidy number). Then sign and date the form and return it to the day care center.

Foster children: If your household includes a foster child who is in child care, write in the names of the foster children.

Section B: Complete this section if you did not complete Section A. Write in your name and the names of all other adults and children living in the

household, including unrelated people, even if they do not have any income. Do not include the children in child care who are listed at the top of the

form.

Enter the amount of income each person received last month, before taxes or anything else was taken out. Refer to the Definition of Income and the

Definition of Household, above. If any amount last month was more or less than the usual, write in that person’s usual income.

The last four digits of the Social Security Number of the adult signing the certification is required. If you do not have a Social Security Number, write

none . The form must be signed by an adult member of the household.

INSTRUCTIONS FOR CENTERS AND SPONSORS

The For Sponsor Use Only section is to be completed, signed and dated by center or sponsor staff. The sponsor/center representative must review

the income eligibility form and ensure that it is completed as indicated in the instructions above. Then indicate the following:

The CACFP Agreement Number.

Total Number of Household Members – This item does not have to be completed if the parent completed Section A. Add those indicated in Section B

(if completed) to the children enrolled in child care and the number of foster children, if applicable.

Total Household Income – This item does not need to be completed if the parent completed Section A. Indicate the total monthly income as calculated

from Section B. If the parent chooses not to disclose income, the form must be categorized as paid.

Number of Free, Reduced or Paid – Compare the total household income and the total number of household members with the current year’s Income

Eligibility Guidelines (CACFP-3687) to determine if the household should be categorized as Free, Reduced or Paid. Use the appropriate column on the

CACFP-3687 to categorize their income. For example, if the parent indicated biweekly income, multiply this amount by 26 to determine yearly income.

Incomplete forms (missing signatures, income information, last four digits of Social Security Number or SNAP, TANF or FDPIR numbers) are categorized

in the paid category.

The income eligibility form is valid until the last day of the month one calendar year from the date it is signed by the household member. For

example, a form signed on May 12, 2014 is valid until May 31, 2015.

DOH-3688 (6/14) Page 2 of 2

Form Doh-3688 - Income Eligibility Form - New York Page 2

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