Cacfp Meal Benefit Income Eligibility Form (Child Care) - 2011
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2CACFP 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)
* IF ALL CHILDREN LISTED BELOW
Names of all household members
ARE FOSTER CHILDREN, SKIP TO
CHECK
(First, Middle Initial, Last)
PART 5 TO SIGN THIS FORM.
IF NO INCOME
Part 2. Benefits: If any member of your household receives SNAP, TANF, or FDPIR, provide the name and case number for
the person who receives benefits. If no one receives these benefits, skip to part 3.
NAME:_________________________________________________ CASE 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 case number:
NAME:
___________________________________ CASE NUMBER:
____________
Check here if no case number
Part 4. Total Household Gross Income—You must tell us how much and how often
B. Gross income and how often it was received
A. Name
1. Earnings from work
2. Welfare, child support,
3. Pensions, retirement,
4. All Other Income
(List only household members with
before deductions
alimony
Social Security, SSI, VA
income)
benefits
(Example)
$200/weekly_____
$150/twice a month_
$100/monthly_____
$200/bi-monthly
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: ____________________________
Address: ___________________________________________
Phone Number: _______________________
City:_______________________________________________
State: ________________
Zip Code: ________________
I do not have a Social Security Number
Last four digits of Social Security Number: _* _* _* - _* _* - __ __ __ __
July 2011
CACFP Meal Benefit Income Eligibility
Child Care Form
Page 1
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