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

CACFP Meal Benefit Form and Instructions

Federal Fiscal Year 2015-2016

twice a month, or monthly.

Box 1: List the gross income, not the take-home pay. Gross income is the amount earned before taxes

and other deductions. You should be able to find it on your stub or your boss can tell you.

Box 2: List the amount each person got for the month from welfare, child support, alimony.

Box 3: List retirement, Social Security, Supplemental Security Income (SSI), Veteran’s (VA) benefits,

disability benefits.

Box 4: List ALL OTHER INCOME SOURCES including Worker’s Compensation, unemployment, strike

benefits, regular contributions from people who do not live in your household, and any other income. For

ONLY the self-employed, report income after expenses in Box 1. Box 4 is for your business, farm or

rental property. Do not include income from SNAP, WIC or Federal education benefits. If you are in the

Military Housing Privatization Initiative or get combat pay, do not include this housing allowance as

income.

Part 5: Adult household member must sign the form and list the last four digits of the Social Security Number or

mark the box if s/he doesn’t have one.

Part 6: Answer this question if you choose.

ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:

Part 1: List all enrolled children and household members. For any people, including children, with no income,

you must check the “No Income Box.”

Part 2: Skip this part.

Part 3: Skip this part.

Part 4: Follow these instructions to report total household income form this month or last month.

Column A – Name: List only the first and last name of each person living in your household who share

income and expenses, related or not (such as grandparents, other relatives, or friends who live with you) with

income. Include yourself and all children living with you. Attach another sheet of paper if you need to.

Column B – Gross Income and How Often it was Received: For each household member, list each type of

income received for the month. You must tell us how often the money is received – weekly, every other week,

twice a month, or monthly.

Box 1: List the gross income, not the take-home pay. Gross income is the amount earned before taxes

and other deductions. You should be able to find it on your stub or your boss can tell you.

Box 2: List the amount each person got from the month from welfare, child support, alimony.

Box 3: List retirement, Social Security, Supplemental Security Income (SSI), Veteran’s (VA) benefits,

disability benefits.

Box 4: List ALL OTHER INCOME SOURCES including Worker’s Compensation, unemployment, strike

benefits, regular contributions from people who do not live in your household, and any other income. For

ONLY the self-employed, report income after expenses in Box 1. Box 4 is for your business, farm or rental

property. Do not include income from SNAP, WIC or Federal education benefits. If you are in the Military

Housing Privatization Initiative or get combat pay, do not include this housing allowance as income.

Part 5: Adult household member must sign the form and list the last four digits of the Social Security Number

or mark the box if s/he doesn’t have one.

Part 6: Answer this question if you choose.

Privacy Act Statement: This explains how we will use the information you give us.

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

CACFP Meal Benefit Income Eligibility

Child Care

July 2015

Cacfp Meal Benefit Form And Instructions Federal - 2015-2016 Page 4

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