Cacfp Meal Benefit Form And Instructions Federal - 2015-2016 printable pdf download

CACFP Meal Benefit Form and Instructions

Federal Fiscal Year 2015-2016

Part 1. All Household Members

Name of Enrolled Child(ren):

CHECK IF A FOSTER CHILD (THE LEGAL

RESPONSIBILITY OF A WELFARE AGENCY OR

COURT)

* IF ALL CHILDREN LISTED BELOW ARE

Names of all household members

FOSTER CHILDREN, SKIP TO PART 5 TO SIGN

CHECK

(First, Middle Initial, Last)

THIS FORM.

IF NO INCOME

Part 2. Benefits: If any member of your household received [State SNAP] or [State TANF cash assistance], 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. If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call [Your School, Homeless

Homeless 

Migrant 

Liaison, Migrant Coordinator at Phone #]

Runaway

Part 4. Total Household Gross Income—You must tell us how much and how often

B. Gross income and how often it was received

A. Name

1. Earnings from work

2. Welfare, child support,

3. Pensions, retirement,

4. All Other Income

(List only household members with

before deductions

alimony

Social Security, SSI, VA

income)

benefits

(Example)

$200/weekly_____

$150/twice a month_

$100/monthly_____

$______/________

Jane Smith

$______/________ $______/________

$______/________

$______/_______

$______/________ $______/________

$______/________

$______/_______

$______/________ $______/________

$______/________

$______/_______

$______/________ $______/________

$______/________

$______/_______

$______/________ $______/________

$______/________

$______/_______

Part 5. 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 or day care home 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: ________________________________________________

Address: ___________________________________________ Phone Number: _______________________

Date: ______________

City:_______________________________________________

State: ________________

Zip Code: ________________

 I do not have a Social Security Number

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

CACFP Meal Benefit Income Eligibility

Child Care

July 2015

Cacfp Meal Benefit Form And Instructions Federal - 2015-2016

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