Cacfp Meal Benefit Income Eligibility Form (Adult Care)

CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Adult Care)

Don’t fill out this part. This is for official use only.

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12



Total Income: ____________ Per:

Week,

Every 2 Weeks,

Twice A Month,

Month,

Year

Household size: _________

Categorical Eligibility: ___ Date Withdrawn: ________ Eligibility: Free___ Reduced___ Denied___

Tier I_____

Tier II____

Reason: _____________________________________________________________________________________________________

Determining Official’s Signature: _______________________________________________________________ Date: ______________

Confirming Official’s Signature: ________________________________________________________________ Date: ______________

Follow-up Official’s Signature: _________________________________________________________________ Date:______________

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 the participant 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 list a Supplemental Nutrition Assistance Program

(SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian

Reservations (FDPIR) case number for the participant or other (FDPIR) identifier 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 the participant is eligible for free or reduced price meals, and for administration and enforcement of the

Program.

Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. “In accordance

with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis

of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of

Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice).

Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service

at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.”

July 2011

CACFP Meal Benefit Income Eligibility

Adult Care Form

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Cacfp Meal Benefit Income Eligibility Form (Adult Care) - 2011 Page 2