Cacfp Meal Benefit Form And Instructions Federal - 2015-2016 (Page 2 of 4) in pdf

Cacfp Meal Benefit Form And Instructions Federal - 2015-2016 Page 2

CACFP Meal Benefit Form and Instructions

Federal Fiscal Year 2015-2016

Part 6. Participant’s ethnic and racial identities (optional)

Mark one ethnic identity:

Mark one or more racial identities:

 Hispanic or Latino



 American Indian or Alaska Native

Asian

 Not Hispanic or Latino



 Native Hawaiian or Other Pacific Islander

White



Black or African American

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

Annual Income: ____________

Household size: _________

Eligibility Determination: Free______ Reduced Price______ Above Scale______

Determining Official’s Signature: ____________________________________________________ Date: ______________

Confirming Official’s Signature: _____________________________________________________ Date: ______________

Income Guidelines for Reduced Priced Meals

Effective July 1, 2015 to June 30, 2016

The participant in the day care facility may qualify for free or reduced price meals if

your household income falls within the limits on this chart.

Household size

Yearly

$25,068

$33,911

$42,754

$51,597

$60,440

$69,283

$78,126

$86,969

Each additional

+$8,843

person:

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 apply on behalf of a foster child or 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.

CACFP Meal Benefit Income Eligibility

Child Care

July 2015

Cacfp Meal Benefit Form And Instructions Federal - 2015-2016 Page 2

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