Iowa Eligibility Application Form (Page 3 of 4) in pdf

Page 1 of 2

Iowa Eligibility Application

Received Date: _______

FFY 14-15

Complete one application per household. School Year 2014-2015



school meals

children in child care center



Part 1. Check all

children in child care home(HP)



special milk (restrictions apply)

Tier I home provider (HP)

applicable boxes:

Provider name:



Head Start/Even Start

Part 2. FIP or Food Assistance Eligible:

Enter the FIP or Food Assistance Case Number for ANY household member as listed in the Notice of

Decision.

NOTE: Medicaid, Title XIX and EBT card numbers are not acceptable. Skip part 5.

Name of household member with Case Number _______________________________ List Case Number _____________________________

Part 3. Check if any child is Homeless, Migrant, or a Runaway and call your child’s school.

 Run away

 Migrant

 Homeless

Part 4. Children enrolled. REQUIRED OF ALL APPLICANTS.

List name(s) of all enrolled child(ren) in your household.

Ethnicity: H=Hispanic or Latino,

Race:

A=Asian

B=Black or African American

I=American Indian or Alaska Native

N=Non Hispanic or Latino

P=Native Hawaiian or other Pacific Islander

W=White

OPTIONAL

Check

Schools Only

Last Name

First Name

Middle Name

box for

Date of

Grade

Name of School/Head Start/

or Initial

FOSTER

Birth

Child Care Center/Home

child

ETHNICITY

RACE



Part 5. Total Household Gross Income.

DO NOT COMPLETE PART 5 IF YOU LISTED A FIP OR FOOD ASSISTANCE NUMBER IN PART 3.

Report the gross income received by EACH household member one time in the correct column: weekly, every 2 weeks, twice a month or monthly.

Gross income is the amount earned before taxes and other deductions, not take-home pay. Report all other monthly income received. Self-

employed persons, see the worksheet on reverse side of this application.

Gross Income: Report income by how

Other Monthly Payments or

List the names of everyone living in your household, including the children listed in Part 4.

often the household member is paid.

Income Received.

Attach a separate page if more space is needed. For FOSTER children, include only

money available for child’s personal use or child’s own income.

Gross

Welfare,

Pension,

All other

Gross

amount

child

retirement,

income

amount

earned

support,

social

Check if

Last Name

First Name

every

twice

monthly

alimony,

security, SSI,

weekly

Age

2 weeks

a month

adoption

VA benefits

Income

subsidies

 I do not have a Social Security Number.

Last four digits of my Social Security Number

X XX - X X - ___ ___ ___ ___

If Part 5 is completed, the adult signing the form must provide the last 4 digits of his or her Social Security Number or mark the "I do not have a Social Security

Number" box. For further information refer to the Privacy Act Statement in the parent letter.

Part 6. Certification and Signature. REQUIRED OF ALL APPLICANTS.

I certify (promise) that all information on this application is true and that all income is reported if required. I understand that I will receive benefits from Federal

funds based on the information I give. I understand that officials may verify (check) the information. I understand that if I purposely give false information, my

children may lose meal/milk benefits, and I may be prosecuted. Email of Adult completing Form_______________________________________________

______________________________________________

_________________________________________________

___________________

Signature of Adult Completing Form

Printed Name of Adult Completing Form

Date Signed

_____________ _______ _____________ ____________

__________

_____________________________________________

Address of Adult Completing Form

Town

ZIP Code

Work Phone

Home Phone

Cell Phone

Part 7. DO NOT WRITE BELOW THIS LINE. FOR ADMINISTRATIVE USE ONLY.

Income conversion factors for annual income:

weekly X 52;

two weeks X 26;

twice a month X 24;

monthly X 12



Household Income: $ ___________

Weekly

Every 2 Weeks

Twice Monthly

Monthly

Annually

Household Size _______

 Income

 Foster Child (free)

 FIP/Food Assistance

Application Approved:

CACFP HP ONLY:

 Head Start DOCUMENTATION REQUIRED

 Tier 1 Area (Provider’s own

 Homeless/Migrant/Runaway (Schools only) -Local Official Documentation Required

children)

 Tier 1 Income (All children)

Eligibility

 Free Meals

 Reduced Price Meals

 Free Milk

 Tier 1 Child (Tier 2 mixed)

Determination:

 Incomplete

 Over income limits

Application Denied:

______________________________________________________

Confirming Official Signature (Schools only)

Date

_____________________________________________

__________________

______________________________________________________

Determining Official Signature

Effective Date

Follow-Up Official Signature (Schools only)

Date

Iowa Eligibility Application Form Page 3

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