Sample Income Eligibility Application Form printable pdf download

Sample INCOME ELIGIBILITY APPLICATION

HILD

ARE

ENTER

EAD

TART

UTRITION

ROGRAM

PART 1 - Child’s Name: ____________________________________ Age: _______ Birth date: ________________

Child’s Normal Child Care Schedule (check all that apply): __Monday __Tuesday __Wednesday __Thursday __Friday __Saturday __Sunday

Child’s Normal Hours of Care (include time and indicate AM or PM): _____AM/PM to_____ AM/PM and _____AM/PM to ___AM/PM

Normal Meal Service(s) Child will be Served: __ Breakfast __A.M. Snack __ Lunch __P.M. Snack __Supper

PART 2A – PARTICIPANTS WHO ARE CATEGORICALLY ELIGIBLE AS FREE FOR CACFP BENEFITS:

Households Receiving SNAP (formerly known as Food Stamps) or TFA BENEFITS; or FOSTER CHILD.

Complete this part and sign the application in Part 3; DO NOT complete Part 2B.

Supplemental Nutrition Assistance Program or SNAP (formerly known as Food Stamps) Case Number: ________________________

TFA

Temporary Family Assistance

Case Number: ________________________

(

)

Check here if Foster Child:

PART 2B - ALL OTHER HOUSEHOLDS: If you did not complete Part 2A, complete this Part and Part

CURRENT MONTHLY INCOME

NAMES

Names of All

Earnings from Work

Welfare, Child Support,

Payments from

Earnings from Job 2

Household Members

(Before Deductions)

Alimony

Pensions, Retirement,

or any Other Income

(include the child listed above)

Job 1

Social Security

1.__________________

$_______________

2.__________________

$_______________

3.__________________

$_______________

4.__________________

$_______________

5.__________________

$_______________

6.__________________

PART 3 - SIGNATURE:

An adult household member must sign and date the application before it can be approved.

PENALTIES FOR MISREPRESENTATION: I certify that all of the above information is true and correct and that the SNAP or TFA number is

current, correct or that all income is reported. I understand that this information is being given for the receipt of Federal funds; that institution

officials may verify the information on the application and that the deliberate misrepresentation of the information may subject me to prosecution

under applicable State and Federal laws.

Signature of adult ______________________________________________ Social Security Number XXX – XX -

__ __ __ __

last 4 digits only

Printed name of adult ____________________________________________ Date signed ____________________________

___________________

_________________________________________________________

_____________

Home telephone

Work telephone

Home Address

Zip code

PART 4 – RACIAL AND ETHNIC IDENTITY:

You are not required to answer this question.

Ethnicity:

[ ] Hispanic or Latino

[ ] Not Hispanic or Latino

Race: [ ] White

[ ] Black or African American

[ ] Asian

[ ] American Indian or Alaskan Native

[ ] Native Hawaiian or Other Pacific Islander

Privacy Act Statement. This explains how the information you provide will be used. Section 9 of the National School Lunch Act requires that unless the participant’s Supplemental Nutrition

Assistance Program (SNAP) or TFA number is provided, you must include the last four digits of the social security number of the household member signing the application or an indication that

the household member signing the application does not possess a social security number. Provision of a social security number is not mandatory, but if the last four digits of the social security

number are not provided or an indication is not made that the adult household member signing the application does not have one, the application cannot be approved. The last four digits of the

social security number may be used to identify the household member in carrying out efforts to verify the correctness of information stated on the application. These verification efforts may be

carried out through program reviews, audits, and investigations and may include contacting employers to determine income, contacting a SNAP or TFA office to determine current certification for

receipt of SNAP or TFA benefits, contacting the State employment security office to determine the amount of benefits received and checking the documentation produced by the household

member to prove the amount of income received. These efforts may result in a loss or reduction of benefits, administrative claims, or legal actions if incorrect information is reported. The last

four digits of the social security number may also be disclosed to programs as authorized under the National School Lunch Act and the Child Nutrition Act, the Comptroller General of the United

States, and law enforcement officials for the purpose of investigating violations of certain Federal, State and local education, health and nutrition programs. Your eligibility information may be

shared with education, health and nutrition programs to help them evaluate, fund or determine benefits for their programs; auditors for program reviews; and law enforcement officials to help them

look into violations of program rules. Your information may also be shared with Medicaid or the State children’s health insurance program (HUSKY), unless you tell us not to, in writing, within

30 days of signing this application. The information, if disclosed, will be used to identify eligible children and seek to enroll them in Medicaid or HUSKY.

For Sponsor Use Only

Weekly X 52  Every 2 Weeks X 26  Twice a Month X 24  Monthly X 12

Annual Income Conversion:

Total family income $___________ Family size ______

OR SNAP/TFA household

Foster Child

Eligible Free:

Eligible Reduced:

Over Income:

Temporary Eligibility: Free:

Reduced:

Time Period:_________