2017-2018 Child And Adult Care Food Program Meal Benefit Income Eligibility Applicati - U.s. Department Of Agriculture

2017-2018 Child and Adult Care Food Program Meal Benefit Income Eligibility Application

Complete one application per household. Please use a pen (not a pencil).

(Child Care Centers)

STEP 1

List ALL Household Members who are infants, children, and students up to and including age 18 (if more spaces are required for additional names, attach another sheet of paper)

Homeless,

Enrolled?

Foster

Migrant,

Child’s First Name

MI

Child’s Last Name

Age

Definition of Household

Yes

No

Runaway

Child

Member: “Anyone who is

living with you and shares

income and expenses, even

if not related.”

Children in Foster care and

children who meet the

definition of Homeless,

Migrant or Runaway are

eligible for free meals. Read

How to Apply for Free and

Reduced Price School

Meals for more information.

STEP 2

Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?

> Go to STEP 3.

Case Number:

If NO

If YES >

Write a case number here then go to STEP 4 (Do not complete STEP 3)

Write only one case number in this space.

Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2)

How often?

A. Child Income

Weekly Bi-Weekly 2x Month

Monthly

Child income

Sometimes children in the household earn or receive income. Please include the TOTAL income received by all

$

Household Members listed in STEP 1 here.

B. All Adult Household Members (including yourself)

Are you unsure what

List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total gross income (before taxes)

for each source in whole dollars (no cents) only. If they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.

income to include here?

How often?

How often?

How often?

Flip the page and review

Public Assistance/

Pensions/Retirement/

Earnings from Work

Weekly

Bi-Weekly 2x Month Monthly

Weekly Bi-Weekly

2x Month Monthly

Weekly

Bi-Weekly 2x Month

Monthly

the charts titled “Sources

Child Support/Alimony

All Other Income

Name of Adult Household Members (First and Last)

of Income” for more

information.

$

$

$

The “Sources of Income

$

$

$

for Children” chart will

help you with the Child

Income section.

$

$

$

The “Sources of Income

for Adults” chart will help

$

$

$

you with the All Adult

Household Members

$

$

$

section.

Last Four Digits of Social Security Number (SSN) of

Total Household Members

X

X

X X

X

Check if no SSN

(Children and Adults)

Primary Wage Earner or Other Adult Household Member

STEP 4

Contact information and adult signature

“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that determining officials may verify (check) the information. I am aware that if I purposely

give false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.”

Street Address (if available)

Apt #

City

State

Zip

Daytime Phone and Email (optional)

Printed name of adult signing the form

Signature of adult

Today’s date