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CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)

Part 1. All Household Members

Name of Enrolled Child(ren):

CHECK IF A FOSTER CHILD (THE

LEGAL RESPONSIBILITY OF A

WELFARE AGENCY OR COURT)

CHECK

* IF ALL CHILDREN LISTED BELOW

Names of all household members

IF NO

ARE FOSTER CHILDREN, SKIP TO

(First, Middle Initial, Last)

INCOME

PART 5 TO SIGN THIS FORM.

Part 2. Benefits: If any member of your household receives SNAP, TANF, or FDPIR, provide the name and eligibility number for the person

who receives benefits. If no one receives these benefits, skip to part 3.

NAME: _______________________________________________ ELIGIBILITY NUMBER: ________________________________

Part 3. (Applies only to parents/guardians with children enrolled in a day care home) If any member of your household receives benefits

listed on the enclosed List of Eligible Federal/State Funded Programs (H1660), provide the name of the program and eligibility number:

NAME:______________________________________ ELIGIBILITY NUMBER: ____________________________

Check here if no case number q

Part 4. Total Household Gross Income―You must tell us how much and how often

B. Gross income and how often it was received

Note: Self-employed report income after expenses in box 1

A. Name

1. Earnings from work

2. Welfare, child

3. Pensions, retirement,

4. All Other Income

(List only household members with

Social Security, SSI, VA

before deductions

support, alimony

income)

benefits

(Example)

$150/twice a month

$100/monthly

$200/bi-monthly

$200/weekly

Jane Smith

$_______/_______

Part 5. Signature and Last Four Digits of Social Security Number (Adult must sign)

An adult household member must sign this form. If Part 4 is completed, the adult signing the form must also list the last four digits of his or her

Social Security Number or mark the "I do not have a Social Security Number" box. (See Privacy Act Statement on the next page.)

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.

Sign here: _________________________________________

Print name:

Date: __________________________

Phone Number:

Address:

City:

State:

Zip Code:

* *

Last four digits of Social Security Number:

__ __ __-__ __-__ __ __ __

I do not have a Social Security Number

CACFP Meal Benefit Income Eligibility

October 2016

Child Care Form

Page 1

Child And Adult Care Food Program (Cacfp) Participant Enrollment Form - Taking Kids Places 140 Page 2

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