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Instructions for Completing the CACFP Meal Benefit Income Eligibility Application

Please use these instructions to help you fill out the application for free or reduced price school meals. You only need to submit one application per household.

The application must be filled out completely. Please follow these instructions in order! Each step of the instructions is the same as the steps on your

application. If at any time you are not sure what to do next, please contact [Facility contact here; phone and email preferred].

PLEASE USE A PEN (NOT A PENCIL) WHEN FILLING OUT THE APPLICATION AND DO YOUR BEST TO PRINT CLEARLY.

STEP 1: LIST ALL HOUSEHOLD MEMBERS WHO ARE INFANTS, CHILDREN, AND STUDENTS UP TO AND INCLUDING AGE 18

Tell us how many infants, children, and school students live in your household. They do NOT have to be related to you to be a part of your household.

Who should I list here? When filling out this section, please include ALL members in your household who are:

•

Children age 18 or under AND are supported with the household’s income;

•

In your care under a foster arrangement, or qualify as homeless, migrant, or runaway youth;

•

Students enrolled at [facility here], regardless of age.

A) List each child’s name. Print each child’s

B) Is the child enrolled at [name

C) Do you have any foster children? If any children

D) Are any children homeless, migrant,

name. Use one line of the application for each

of facility here]? Mark ‘Yes’ or

listed are foster children, mark the “Foster Child”

or runaway? If you believe any child

child. When printing names, write one letter in

‘No’ under the column titled

box next to the child’s name. If you are ONLY

listed in this section meets this

each box. Stop if you run out of space. If there

“Enrolled” to tell us which children

applying for foster children, after finishing STEP 1,

description, mark the “Homeless,

are more children present than lines on the

attend [name of facility here]. If

go to STEP 4.

Migrant, Runaway” box next to the

application, attach a second piece of paper

you marked ‘Yes,’ write the age of

Foster children who live with you may count as

child’s name and complete all steps of

with all required information for the additional

the student in the ‘Age’ column to

members of your household and should be listed on

the application.

children.

the right.

your application. If you are applying for both foster

and non-foster children, go to step 3.

STEP 2: DO ANY HOUSEHOLD MEMBERS CURRENTLY PARTICIPATE IN SNAP, TANF, OR FDPIR?

If anyone in your household (including you) currently participates in one or more of the assistance programs listed below, your children are eligible for free school meals:

•

The Supplemental Nutrition Assistance Program (SNAP) for Arizona.

•

Temporary Assistance for Needy Families (TANF) for Arizona.

•

The Food Distribution Program on Indian Reservations (FDPIR) for Arizona.

A) If no one in your household participates in any of the above

B) If anyone in your household participates in any of the above listed programs:

listed programs:

•

Write a case number for SNAP, TANF, or FDPIR. You only need to provide one case number.

•

Leave STEP 2 blank and go to STEP 3.

•

Go to STEP 4.

STEP 3: REPORT INCOME FOR ALL HOUSEHOLD MEMBERS

How do I report my income?

•

Use the charts titled “Sources of Income for Adults” and “Sources of Income for Children,” printed on the back side of the application form to determine if your household has

income to report.

•

Report all amounts in GROSS INCOME ONLY. Report all income in whole dollars. Do not include cents.

Gross income is the total income received before taxes

Many people think of income as the amount they “take home” and not the total, “gross” amount. Make sure that the income you report on this application has NOT been

reduced to pay for taxes, insurance premiums, or any other amounts taken from your pay.