Cacfp Meal Benefit Income Eligibility Form (Child Care) - 2011 Page 2
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2CACFP 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
Asian
American Indian or Alaska Native
Not Hispanic or Latino
White
Native Hawaiian or Other Pacific Islander
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:
Week,
Every 2 Weeks,
Twice A Month,
Month,
Year
Household size: _________
Categorical Eligibility: ___ Date Withdrawn: ________ Eligibility: Free___ Reduced___ Denied___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) case 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: This explains what to do if you believe you have been treated unfairly. “In accordance
with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis
of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of
Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice).
Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service
at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.”
July 2011
CACFP Meal Benefit Income Eligibility
Child Care Form
Page 2
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