Form Isbe 69-88 - Household Eligibility Application For Child Care Centers (Page 2 of 2) in pdf

PARENT INSTRUCTIONS

HOUSEHOLD ELIGIBILITY APPLICATION

Follow These Instructions and Return the Completed form to your Center. Once approved for meal benefits, a child’s Household Eligibility Application is

effective for 12 months.

FOSTER CHILD(REN)

A foster child remains the legal responsibility of the State through a foster care agency or the court. If you submit documentation from the state or local

agency that the child is in foster care, that documentation replaces completing a household eligibility application.

1) If all children in your household (who attend this center) are foster children that are the legal responsibility of a foster care agency or court,

provide the following:

•

Part 1—List the name(s) and age(s) of your foster child(ren) attending this center.

•

Part 2—Check the box(es) indicating a foster child(ren).

•

Part 3—5 Skip

•

Part 6—Provide a signature of an adult household member and date the application.

•

Part 7-8 (OPTIONAL)

2) If you have some foster children that are the legal responsibility of a foster care agency or court along with other children attending this center,

please provide the following:

•

Part 1—List ALL household members, including the foster child(ren), and the age(s) of the child(ren) attending the center.

•

Part 2—Check the box(es) identifying the foster child(ren).

•

Part 3—Record a valid SNAP/TANF case number if applicable

•

Part 4—Skip

•

Complete Parts 5 and 6 if applicable. See the instructions for INCOME–HOUSEHOLDS REPORTING section.

•

Part 7-8 (OPTIONAL)

SNAP OR TANF BENEFITS - HOUSEHOLDS RECEIVING

If any member (child or adult) of your household receives SNAP or TANF benefits, provide the following:

•

Part 1—List ALL people in your household (including grandparents, other relatives, or friends who live with you) and the age(s) of the child(ren)

attending the center.

•

Part 2—Skip

•

Part 3—Record a valid SNAP or TANF case number for any member (child or adult) of this household. You will find your SNAP or TANF case

number on your letter of eligibility for benefits.

•

Part 4—5 Skip

•

Part 6—Provide a signature of an adult household member and date the application.

•

Part 7-8 (OPTIONAL)

HOMELESS, MIGRANT, OR RUNAWAY

If no one in your household receives SNAP or TANF benefits and if any child is homeless, a migrant or runaway, follow these instructions.

•

Part 1—List ALL household members, and the age(s) of the child(ren) attending the center.

•

Part 2—3 Skip

•

Part 4—If any child you are applying for is homeless, migrant, or a runaway, check the appropriate box and call your local school.

•

Part 5—Complete only if a child in your household isn’t eligible under Part 4. See instructions for INCOME–HOUSEHOLDS

REPORTING section below and complete Part 5 and 6.

•

Part 6—Provide a signature of an adult household member and date the application.

•

Part 7-8 (OPTIONAL)

INCOME - HOUSEHOLDS REPORTING

If no one in your household receives SNAP or TANF benefits, please report all household income. The Household Eligibility Application must include the

following information:

•

Part 1—List the names of ALL household members and the age(s) of the child(ren) attending the child care center.

•

Part 2—4 Skip

•

Part 5—List total gross income (before deductions), not take-home pay; and the frequency, how often the money is received, for

each household member for last month. If the income last month was not the usual amount you normally receive, you may provide

a projected amount that better represents your gross income.

o For ONLY the self-employed, list income after expenses. This is for your business, farm, or rental property.

o If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income.

o If you have no income, list zero in the earnings from work column.

•

Part 6—Provide a signature of an adult household member and date the application. Also, provide the last four digits of the social

social security number for the adult signing the application. If you refuse to provide the last four digits of the social security number, the application

cannot be approved. If the adult does not have a social security number, mark the box, I do not have a social security number.

•

Part 7-8 (OPTIONAL)

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies,

offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color,

national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons

with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language,

etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities

may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other

than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at:

, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the

information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1)

mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;

(2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. This institution is an equal opportunity provider.

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

Form Isbe 69-88 - Household Eligibility Application For Child Care Centers Page 2

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