Cacfp Meal Benefit Income Eligibility Form (Adult Care)

CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Adult Care)

Part 1. All Household Members

Name of Enrolled Adult(s): (List name under Names of Adult Participants)

Names of Adult Participants

CHECK

(First, Middle Initial, Last)

IF NO INCOME

Part 2. Benefits: If any member of your household received [State SNAP], [FDPIR], [State SSI] or [Medicaid], 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: _________________________________



TYPE OF BENEFIT (CHECK ONE):

SNAP

FDPIR

SSI

Medicaid

Part 3. Total Household Gross Income—You must tell us how much and how often

B. Gross income and how often it was received

A. Name

(List only the participant(s), spouse

1. Earnings from work

2. Welfare, child support,

3. Pensions, retirement,

4. All Other Income

and dependent children of

before deductions

alimony

Social Security, SSI, VA

participant(s))

benefits

(Example)

$200/weekly_____

$150/twice a month_

$100/monthly_____

$______/________

Jane Smith

$______/________ $______/________

$______/________

$______/_______

$______/________ $______/________

$______/________

$______/_______

$______/________ $______/________

$______/________

$______/_______

$______/________ $______/________

$______/________

$______/_______

Part 4. Signature and Last Four Digits of Social Security Number

An adult household member must sign this form. If Part 3 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

Statement on the back of this 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: _* _* _* - _* _* - __ __ __ __

Part 5. 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

July 2016

CACFP Meal Benefit Income Eligibility

Adult Care Form

Page 1 of 2

Cacfp Meal Benefit Income Eligibility Form (Adult Care) - 2016

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