Enrollment & Income Eligibility Form For Child Care Centers Page 2

ENROLLMENT & INCOME ELIGIBILITY FORM FOR CHILD CARE CENTERS

JULY 1, 2015 THROUGH JUNE 30, 2016

Part 1.

CHILD ENROLLMENT: Complete the information below for all children in care. If the child is a foster child (legal responsibility

of a foster care agency or the court), please check the box.

Meals Served

Ethnicity/

Times of Care

Regular Days of Care

Date of

Foster

During Care

Race*

Birth

Child

Arrival

Leave

A

P

E

M

T

W

T

F

S

S

B

L

D

Ethnicity

Race

Last Name, First Name

Time

Time

M

M

V









*Ethnicity

: H=Hispanic or Latino or N=Not Hispanic or Latino

(select one)

*Race

: W=White, B=Black or African American, I=American Indian or Alaskan Native, A=Asian, or P=Native Hawaiian or other Pacific Islander

(select one or more)

Part 2.

HOUSEHOLDS RECEIVING BENEFITS FROM THE

FOOD ASSISTANCE PROGRAM (FAP), TEMPORARY ASSISTANCE FOR FAMILIES

Complete Parts 1, 2 and 4.

(TAF), OR FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS (FDPIR):

Program Name: ___________________________________________________________ Case No. _____________________________

Part 3A. HOUSEHOLDS EXCEEDING THE INCOME GUIDELINES: Complete Parts 1, 3A and 4.



If your family income exceeds the income guidelines (

), check this box

listed on reverse side

Part 3B. ALL OTHER HOUSEHOLDS – If you do not have a FAP, TAF or FDPIR case number: Complete Parts 1, 3B and 4.

GROSS INCOME BEFORE ANY DEDUCTIONS (Net for Self Employed)

W=Weekly E2=Every 2 weeks 2M=Twice monthly M=Monthly Y=Yearly

Welfare, Child Support,

Pensions, Retirement,

Check

List the Names of All Household

Earnings from Work

All Other Income

If

Alimony

Social Security

ZERO

Members not listed in Part 1

income

How much?

How often?

How much?

How often?

How much?

How often?

How much?

How often?

(Example) Jane Smith

$200

W

$150

2M

$100

M



1



2



3



4



5



6

Social Security Number of Household Member who signs form:



Last four digits of Social Security Number:

-

-____________

If you do not have a Social Security Number, check this box

XXX

XX

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 Food Assistance Program (FAP), Temporary Assistants for Families (TAF) or Food Distribution Program on Indian Reservation (FDPIR) case number for your child 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 your child is eligible for free or reduced price meals, and

for administration and enforcement of the CACFP.

Part 4. SIGNATURE AND CONTACT INFORMATION:

________________________________________________

Print Name

I certify that all information on this form is true and that all

________________________________________________

income is reported. I understand that the facility will receive

Address

Federal funds based on the information I give. I understand that

________________________________________________

CACFP officials may verify the information. I understand that if I

City

State

Zip Code

purposely give false information, the participant receiving meals

________________________________________________

may lose their meal benefits, and I may be prosecuted.

Daytime Telephone

________________________________________________

Employer(s)

_____________________________________

Signature of Parent or Guardian

Date

FOR CENTER USE ONLY

_____ FAP/TAF/FDPIR HOUSEHOLD



HOUSEHOLD CATEGORY:

Free





Reduced Price

Homeless Documentation from school, emergency shelter, or agency

_____





Paid

_____ ANNUAL INCOME: _________________

HOUSEHOLD SIZE: _________

Foster Child – Free Category

List name of foster child(ren):

__________________________________________________________________

Sponsor’s Determining Signature

Date

__________________________________________________________________

Sponsor’s Confirming Signature

Date