Form H1531 - Child Nutrition Program Application printable pdf download

Texas Department of

Form H1531

Agriculture

July 2009

Child and Adult Care Food Program and Summer Food Service Program

Child Nutrition Program Application

Part 1. Children or adults enrolled to receive day care. (Use a separate application for each foster child)

SNAP, TANF or FDPIR case # for children only. All the

above or SSI or Medicaid case # for adults only.

Names

Skip to Part

(First, Middle Initial, Last)

5 if you listed a case #

Part 2. Foster Child: In certain cases, foster children are eligible for free and reduced-price meals regardless of household income. If

foster children live with you, please contact your child care center/sponsor. Skip to Part 5.

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

B. Gross income and how often it was received

Example: $100/monthly $100/twice a month $100/every other week $100/weekly

A. Name

C. Check

(List everyone in household, including

1. Earnings from work

2. Welfare, child

3. Social Security,

4. All Other Income

if NO

children)

before deductions

support, alimony

pensions, retirement,

income

______/________

$______/________

$______/_______

$______/________

$______/_______

$______/________

$______/_______

$______/________

$______/_______

$______/________

$______/_______

$______/________

$______/_______

$______/________

$______/_______

Part 4. Disclosure of Information

The above household income information may be disclosed for the purpose of enrolling children in the children’s health insurance

program. 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

do not

elect to allow my household information to be disclosed.

Part 5. Signature and Social Security Number (Adult must sign)

An adult household member must sign this form. If Part 3 is completed, the adult signing the form must also list his or her Social

Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act 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: X______________________________Print name:_____________________________Date: ______________

Address:_______________________________________________________Phone Number:______________________

__ __ __ - __ __ - __ __ __ __

Social Security Number:

I do not have a Social Security Number

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

Form H1531 - Child Nutrition Program Application

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