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CHILD AND ADULT CARE FOOD PROGRAM

MEAL BENEFIT INCOME ELIGIBILITY FORM INSTRUCTIONS (Family Day Care Home-Provider)

FISCAL YEAR 2018

Instructions For Completing The CACFP Meal Benefit Income Eligibility Form

Follow these instructions, if your household gets SNAP, TANF, or FDPIR:

Part 1: List all household members, including children in child care.

Part 2: List the case number for any household member receiving SNAP or TANF or FDPIR benefits.

Part 3: Skip this part.

Part 4: Sign the form. The last four digits of a Social Security Number is not necessary.

Part 5: Skip this part.

Part 6: Answer this question if you choose.

Follow these instructions, If you are applying on behalf of a FOSTER CHILD, follow these instructions:

If all children you are applying for are foster children, or if you are only applying for benefits for the foster child:

Part 1: List all foster children. Check the box indicating that the child is a foster child.

Part 2: Skip this part.

Part 3: Skip this part.

Part 4: Sign the form. A Social Security Number is not necessary.

Part 5: Skip this part.

Part 6: Answer this question if you choose.

If some of the children in the household are foster children:

Part 1: List all household members. For any person, including children, with no income, you must check the “No Income Box.” Check the

box if the child is a foster child.

Part 2: If the household does not have a case number, skip this part.

Part 3: If no you skipped part 2, follow these instructions to report total household income from this month or last month:

Column A – Name: List only the first and last name of each person living in your household, related or not (such as

grandparents, other relatives, or friends who live with you) with income. Include yourself and all children living with you. Attach

another sheet of paper if needed.

Column B – Gross Income and How Often it was Received: for each household member, list each type of income received for

the month. You must tell us how often the money is received – weekly, every other week, twice a month or monthly:

In Box 1: List the gross income, not the take-home pay. Gross income is the amount earned before taxes and other

deductions. You should be able to find it on your stub or your boss can tell you.

In Box 2: List the amount each person got from the month from welfare, child support, and alimony.

In Box 3: List retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), disability

benefits.

In box 4: List ALL OTHER INCOME SOURCES including Worker’s Compensation, unemployment, strike benefits, regular

contributions from people who do not live in your household, and any other income. For ONLY the self-employed,

under Earnings From Work, report income after expenses. This is for your business, farm or rental property. Do not

include income from DES Food Stamps, FDPIR, WIC or Federal education benefits. If you are in the Military

Housing Privatization Initiative or get combat pay, do not include this housing allowance as income.

Part 4: Adult household member must sign the form and list the last four digits of the Social Security Number.

Part 5: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your school, homeless

liaison, or migrant coordinator. If not applicable, skip this part.

Part 6: Answer this question if you choose.

ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:

Part 1: List all household members. For any person, including children, with no income, you must check the “No Income Box.”

Part 2: Skip this part.

Part 3: Follow these instructions to report total household income from this month or last month.

Column A–Name: List only the first and last name of each person living in your household, related or not (such as grandparents,

other relatives, or friends who live with you) with income. Include yourself and all children living with you. Attach another sheet of

paper if needed.

Column B – Gross Income and How Often it was Received: for each household member, list each type of income received for

the month. You must tell us how often the money is received – weekly, every other week, twice a month or monthly:

In Box 1: List the gross income, not the take-home pay. Gross income is the amount earned before taxes and other

deductions. You should be able to find it on your stub or your boss can tell you.

In Box 2: List the amount each person got from the month from welfare, child support, alimony.

In Box 3: List retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), disability

benefits.

In box 4: List ALL OTHER INCOME SOURCES including Worker’s Compensation, unemployment, strike benefits, regular

contributions from people who do not live in your household, and any other income. For ONLY the self-employed,

under Earnings From Work, report income after expenses. This is for your business, farm or rental property. Do not

include income from DES Food Stamps, FDPIR, WIC or Federal education benefits. If you are in the Military

Housing Privatization Initiative or get combat pay, do not include this housing allowance as income.

Part 4: An adult household member must sign the form and list the last four digits of his or her Social Security Number.

Part 5: Skip this part.

Part 6: Answer this question if you choose.

FY 2018 - CACFP Meal Benefit Income Eligibility Form Instructions For Family Day Care Home-Provider

Instructions For Completing The Cacfp Meal Benefit Income Eligibility Form - Arizona Department Of Education - 2018

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