Child And Adult Care Food Program Income Eligibility Form - 2016-2017

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Part 1 - List name and age of each child enrolled. Indicate each child’s race and ethnicity. If this information is left blank, the institution
representative may complete it based on visual identification. This information is for statistical reporting requirements and does not affect
eligibility. Note: A =Asian; AI/AN=American Indian or Alaskan Native; B/AA=Black or African American; H/PI=Native Hawaiian or other
Pacific Islander; W=White.
First Name
Last Name
Age
Ethnicity (select one) and Race (select one or more)
Ethnicity:  Hispanic or Latino  Not Hispanic or Latino
Race:
 A  AI/AN  B/AA  H/PI  W
Ethnicity:  Hispanic or Latino  Not Hispanic or Latino
Race:
 A  AI/AN  B/AA  H/PI  W
Ethnicity:  Hispanic or Latino  Not Hispanic or Latino
Race:
 A  AI/AN  B/AA  H/PI  W
Participation in some programs allows automatic eligibility for free meals in the CACFP with required documentation. If applicable,
please check one of these boxes if one or more children listed above is:
 A foster child who is the responsibility of the State or was placed by the court.  An Early Head Start, or Head Start child or pregnant
mother or an Even Start enrolled child.  A homeless, migrant, or runaway child. Refer to the back of this page for required eligibility
documentation.
Please note: If you marked one of the boxes listed above and it applies to ALL children listed above, SKIP TO PART 5 – Signature.
Part 2 - Assistance Programs: Does anyone in your household receive benefits from any of the programs listed below? If no, go to Part 3.
If yes, please mark which assistance program (only one is required), write the case number, and SKIP TO PART 5 – Signature.
 Supplemental Nutrition Assistance Program (SNAP)
 Temporary Assistance for Needy Families (TANF)
CASE NUMBER
.
 Food Distribution Program on Indian Reservations (FDPIR)
(Quest Card or Social Security numbers are not acceptable)
Part 3 - Income to report: List the names of all household members who are not listed in Part 1, regardless of age. Write the amount of income
received by each household member for the current month, projected income for the first month of this application, or the month prior to
this application. Indicate if income is weekly (W), monthly (M), or annually (A). If you enter ‘0’ or leave any fields blank, you are stating
there is no income to report. Refer to the back of this page for definitions of income.
Gross Income/
TOTALS
First and Last Name
Other Income
Salary/Wages
Center Use Only
$
W M A
$
W M A
$
W M A
$
W M A
$
W M A
$
W M A
$
W M A
$
W M A
$
W M A
$
W M A
$
W M A
$
W M A
Total number in Household
Note: If necessary, convert multiple income schedules to annual
Total Income:
$
W M A
income. Multiply weekly income by 52, bi-weekly by 26,
monthly by 12.
Part 4 – Social Security Number (SSN): If the adult household member completing this form does not provide a TANF, SNAP, or FDPIR number in
Part 2, the person completing this form must provide the last four digits of his/her Social Security Number (SSN).
 Check if no SSN
X
X
X
-
X
X
-
Part 5 - Signature: I certify that all of the information on this form is true and correct and is given in connection with the receipt of Federal
Funds. Information may be verified. Deliberate misrepresentation may subject me to prosecution under applicable State and Federal
criminal statutes. Note: If the child is a foster child, an official of a court or other agency with responsibility for the child may sign this
form.
.
.
Signature of Adult Household Member
Street Address
.
.
Printed Name
City
State
Zip Code
.
.
.
Date
Home Telephone
Work Phone
J:\Institution Forms & Manuals
IEFs, Letters, HHGs, Rates Forms\FY 16\2016-2017 IEF child care FINAL.doc
\

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