Meal Benefit Income Eligibility Form - Arizona Department Of Education

CHILD AND ADULT CARE FOOD PROGRAM

MEAL BENEFIT INCOME ELIGIBILITY FORM (Adult Care)

FISCAL YEAR 2018

Part 1. All Household Members - Name of Enrolled Adult(s):

DATE OF

BIRTH

CHECK

Names of Adult Participants (First, Middle Initial, Last)

(MM/DD/YY)

IF NO INCOME

Part 2. Benefits: If any member of your household received SNAP, FDPIR, State SSI or AHCCCS, 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. Total Household Gross Income (income before any deductions) —You must tell us how much and how often

B. Gross income and how often it was received: identify weekly, every other week, monthly, yearly…

A. Name (List all people living in the

3. Pensions, retirement,

household, including spouse and/or

1. Earnings from work before

2. Welfare, child support,

Social Security, SSI, VA

children)

deductions

alimony

benefits

4. All Other Income

how much/how often

$______/________

$______/_______

$______/________

$______/_______

$______/________

$______/_______

$______/________

$______/_______

Part 4. Signature and Last Four Digits of Social Security Number: A responsible adult 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 write the word None if the

signer doesn’t have a Social Security Number. (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 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: ________________

Last four digits of Social Security Number: _* _* _* - _* _* - _____ _____ _____ _____

If no SSN, write the word “None.” __________________

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

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/Income Eligibility:

Free_________ Reduced_________ Paid_________

Determining Official’s Signature: _______________________________________________________________ Date: ______________

Confirming Official’s Signature: ________________________________________________________________ Date: ______________

FY 2018 - CACFP Meal Benefit Income Eligibility Form-Adult Care

Meal Benefit Income Eligibility Form - Arizona Department Of Education - 2018 Page 2

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