Cacfp Meal Benefit Income Eligibility Form (Adult Care)

CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Adult Care)

Part 1. All Household Members

Name of Enrolled Adult(s):

Names of Household Members (including enrolled adult(s))

CHECK

(First, Middle Initial, Last)

IF NO INCOME

Part 2. Benefits: If any member of your household receives SNAP, TANF, FDPIR, SSI or Medicaid, provide the name and

case number for the person who receives benefits. If no one receives these benefits, skip to part 3.

NAME:

________________________________________________ CASE NUMBER:

________________________

Part 3. Total Household Gross Income—You must tell us how much and how often

B. Gross income and how often it was received

A. Name

(List only participant(s), spouse and

1. Earnings from work

2. Welfare, child support,

3. Pensions, retirement,

4. All Other Income

dependent children of participant(s)

before deductions

alimony

Social Security, SSI, VA

with income)

benefits

(Example)

$200/weekly_____

$150/twice a month_

$100/monthly_____

$200/bi-monthly

Jane Smith

Part 4. Signature and Last Four Digits of Social Security Number (Adult must sign)

An adult household member must sign this form. If Part 3 is completed, the adult signing the form must also list the last

four digits of his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See

Privacy Act Statement on the back of this page.)

I certify that all information on this form is true and that all income is reported. I understand that the center will get Federal

funds based on the information I give. I understand that CACFP officials may verify the information. I understand that if I

purposely give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted.

Sign here: _________________________________________

Print name: ________________________________________

Date: ____________________________

Address: ___________________________________________

Phone Number: _______________________

City:_______________________________________________

State: ________________

Zip Code: ________________

 I do not have a Social Security Number

Last four digits of Social Security Number: _* _* _* - _* _* - __ __ __ __

Part 5. Participant’s ethnic and racial identities (optional)

Mark one ethnic identity:

Mark one or more racial identities:

Hispanic or Latino

Asian

American Indian or Alaska Native

Not Hispanic or Latino

White

Native Hawaiian or Other Pacific Islander

Black or African American

July 2011

CACFP Meal Benefit Income Eligibility

Adult Care Form

Page 1

Cacfp Meal Benefit Income Eligibility Form (Adult Care) - 2011

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