Form Isbe 69-88 - Household Eligibility Application For Child Care Centers printable pdf download

HOUSEHOLD ELIGIBILITY APPLICATION FOR CHILD CARE CENTERS

CHILD AND ADULT CARE FOOD PROGRAM

All Household Members

NAMES OF ALL HOUSEHOLD MEMBERS

FOSTER CHILD

SNAP OR TANF CASE NUMBER

Skip to Part 6 if you list a SNAP or

TANF case number. At least one SNAP/TANF must be provided below.

Ages of Children

First, Middle Initial, Last

Foster children are a legal responsibility

at Center

of DCFS or court. If all are foster children,

skip to #6.

Homeless, Migrant, or Runaway

Homeless

Migrant

Runaway

______________________________________________________________________

__________________

Signature of School Homeless Liaison or Migrant Coordinator

Date

Total Household Gross Income (before deductions) You must tell us how much and how often.

GROSS INCOME AND HOW OFTEN IT WAS RECEIVED (Example: $100/month; $100 /twice a month; $100/every other week; $100/week)

NAMES

Earnings From Work

Welfare, Child

Pensions, Retirement,

Worker’s Comp., Unemploy-

(LIST ALL HOUSEHOLD MEMBERS

ment, SSI, etc. (All other income)

(Before Deductions)

Support, Alimony

Social Security

WITH INCOME)

Amount

How often?

Amount

How often?

Amount

How often?

Amount

How often?

ii.

iii.

iv.

Signature and Social Security Number (Adult must sign)

x x x

x x

__ __ __ - __ __ - __ __ __ __

An adult household member must sign the application. If Part 5 is completed or if zero income is

I do not have a social

listed, the adult signing the form must also list the last four digits his or her social security number

security number.

Social Security Number

or mark the I do not have a social security number box.

I certify all information on this application is true and all income is reported. I understand the center will get federal funds based on the information I give. I understand the institution, Illinois

State Board of Education, or Office of Inspector General, may verify this information on the application. Deliberate misrepresentation of the information may subject me to prosecution under

applicable state and federal laws.

_________________________

_________________________________________

_________________________________________________________

Date

Printed Name of Adult Household Member

Signature of Adult Household Member

Contact Information (Optional)

________________________________________

______________________________________ ________________________________________________________________

Work Telephone Number (Include Area Code)

Home Telephone Number (Include Area Code)

Home Address (Number, Street, City, State, Zip Code)

Optional – Sharing Information With All Kids Insurance Program

May we share your information on this application with the All Kids Insurance Program, the complete health insurance program for every child in Illinois? If yes, do not sign below.

No, I do not want my information from this application shared with the All Kids Insurance Program.

Date: _______________________________

Sign here: ___________________________________________________________

PRIVACY ACT STATEMENT: The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we

cannot approve your child for free or reduced-price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The

social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families

(TANF) Program, or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member

signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced-price meals, and for administration and

enforcement of the Child and Adult Care Food Program. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine

benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.

CHILD CARE REPRESENTATIVE USE ONLY—ELIGIBILITY DETERMINATION - COMPLETE SECTIONS A, B and C BELOW

Follow the Instructions for Institutions to Process Household Eligibility Applications available at

Convert income only if different

SECTION A

Annual Income Conversion Weekly X 52

Every 2 Weeks X 26

Twice a Month X 24

Once a Month X 12

frequencies of pay are reported.

TOTAL

INCOME $ ____________________ Per:

Week

Every 2 Weeks

Twice a Month

Month

Year

NUMBER IN HOUSEHOLD: ______

Free based on:

Reduced based on:

Denied—Reason:

foster child

migrant

household’s income

income too high

SNAP or TANF

runaway

incomplete application

homeless

household’s income

Non-qualifying SNAP/TANF

SECTION B

Signature of Determining Official ___________________________________________________________ Date _____________________________________

SECTION C

Effective Date of this application: _____________________________________

The effective date may be made retroactive back to the first day the child participates in the CACFP as long as it occurs in the same month in which the child’s eligibility

is certified.

ISBE 69-88 (4/17) Effective July 1, 2017

Form Isbe 69-88 - Household Eligibility Application For Child Care Centers

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