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CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)

Part 6. Participant's ethnic and racial identities (optional)

Mark one ethnic identity:

Mark one or more racial identities:

Hispanic or Latino

American Indian or Alaska Native

Asian

Not Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Black or African American

Part 7. Sharing Information With Other Programs: OPTIONAL

The above information may be disclosed for the purpose of enrolling children in the Children's Health Insurance Program

(CHIP). Parents/guardians are not required to consent to such disclosure and electing not to allow disclosure will not

adversely affect a child's eligibility.

I do elect to allow my household information to be disclosed.

I do not elect to allow my household information to be disclosed.

Don't fill out this part. This is for official use only.

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12

Total Income:___________ Per:

: ______________

Month

Twice A Month

Year

Household size

Week

Every 2 Weeks

Categorical Eligibility:____ Date Withdrawn:

Eligibility: Free____ Reduced____ Denied ___ Tier I____ Tier II ____

Reason:_____________________________________________________________________________________________________________

Determining Official's Signature: _________________________________________________________________ Date: _________________

Confirming Official's Signature: __________________________________________________________________ Date: ________________

Follow-up Official's Signature: ___________________________________________________________________ Date: ________________

Privacy Act Statement:

The Richard B. Russell National School Lunch Act requires the information on this application. 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 application. The Social Security Number is not required when you apply on behalf of a foster child or you list a Supplemental

Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations

(FDPIR) eligibility number for the participant or other (FDPIR) identifier or when you indicate that the adult household member signing the application

does not have a Social Security Number. We will use your information to determine if the participant is eligible for free or reduced price meals, and for

administration and enforcement of the Program.

Non-discrimination Statement:

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

(2) fax: (202) 690-7442; or (3) email:

program.intake@usda.gov.

Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW