Child And Adult Care Food Program Income Eligibility Form

Gross Income/Salary/Wages includes, but is not limited to:

 Gross earned income or cash income before deductions.

 Monetary compensation for services, including wages, salary, tips, strike benefits, commissions, fees, withdrawals from savings,

investments, trust accounts, and other accounts.

 Net income from self-owned businesses and farms.

 Social Security, public assistance or Welfare payments (e.g. TANF, General Assistance/General Relief), alimony, child support payments,

and unemployment and worker’s compensation.

 Private pensions or annuities, retirement benefits, disability benefits, veteran’s benefits, dividends or interest, income from estates,

trusts or investments, net rental income, cash withdrawals from savings, and net royalties.

 Student financial assistance (grants or scholarships) not used to meet education expenses.

 Regular contributions from persons not living in the household or any other money that may be available to pay for child (ren)’s meals.

 Child’s income: The current earnings of a child or student grade 12 or below, regardless of age, who is a full-time or regular part-time

employee, or who receives income from other sources, such as SSI or social security. Infrequent earnings, such as income from

occasional baby-sitting or mowing lawns, are not counted as income and should not be listed on the application.

The following documentation is required for automatic eligibility:

 Documentation from the placement agency verifying the child is a foster child.

 One of the following documents from the Head Start program: 1) An approved Head Start or Even Start application; 2) A statement of

Head Start or Even Start enrollment; 3) A list of participants from the Even Start or Head Start official; 4) Documentation from the Even

Start official that confirms the child has not entered Kindergarten.

 Documentation verifying the status of a homeless, migrant or runaway child from the director of the homeless shelter, Migrant Education

Program Coordinator or an official of the Runaway and Homeless Youth program.

FOR CENTER STAFF USE ONLY



Income Category (check one):

Free

Reduced

Paid (Ineligible for Free or Reduced Priced meals)

This form expires 12 months after the month in which the institution makes the determination. Example: If the determination is July 2016, the form is

valid from July 1, 2016 through July 31, 2017. The institution may use the date the parent/guardian signs the Income Eligibility Form, OR the date

the institution’s official makes the determination and signs the Income Eligibility Form. The same approval method selected must be used for all

forms approved by the institution.

Determination Date:

Signature of Center’s Eligibility Official

Month

Year

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its

Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based

on 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 USDA. Persons with disabilities who require alternative means of communication for program information (e.g.

Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits.

Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.

Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination,

complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at:

, and at any USDA office, or write a letter addressed to USDA and provide in the

letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed

form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence

Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. This institution is an equal

opportunity provider.

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IEFs, Letters, HHGs, Rates Forms\FY 16\2016-2017 IEF child care FINAL.doc

Child And Adult Care Food Program Income Eligibility Form - 2016-2017 Page 2

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