7 CFR 226 - Household Burden

TEMPLATE - CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM OMB Number: 0584-0055

(Child Care) Expiration Date: XX/XX/20xx

Part 1. All Household Members
Name of Enrolled Child(ren):
Names of all household members (First, Middle Initial, Last)			Check if a foster child (the legal responsibility of a welfare agency or court) * If all children Listed below are foster children, skip to Part 5 to sign this form.			Check if NO income
Part 2. Benefits: If any member of your household received [State SNAP], [FDPIR], 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 Liaison, Migrant Coordinator at Phone #] Homeless  Migrant  Runaway
Part 4. Total Household Gross Income—You must tell us how much and how often
A. Name (List only household members with income)	B. Gross income and how often it was received
	1. Earnings from work before deductions	2. Welfare, child support, alimony		3. Pensions, retirement, Social Security, SSI, VA benefits	4. All Other Income
(Example) Jane Smith	$200/weekly_____	$150/twice a month_		$100/monthly_____	$______/________
	$______/________	$______/________		$______/________	$______/_______
	$______/________	$______/________		$______/________	$______/_______
	$______/________	$______/________		$______/________	$______/_______
	$______/________	$______/________		$______/________	$______/_______
	$______/________	$______/________		$______/________	$______/_______
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 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: ________________________________________ Date: ____________________________ Address: ___________________________________________ Phone Number: _______________________ City:_______________________________________________ State: ________________ Zip Code: ________________ Last four digits of Social Security Number: _* _* _* - _* _* - __ __ __ __  I do not have a Social Security Number

Part 6. Participant’s ethnic and racial identities (optional)
Mark one ethnic identity:	Mark one or more racial identities:
 Hispanic or Latino  Not Hispanic or Latino	Asian  American Indian or Alaska Native White  Native Hawaiian or Other Pacific Islander 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 Total Income: ____________ Per:  Week,  Every 2 Weeks,  Twice A Month,  Month,  Year Household size: _________ Categorical Eligibility: ___ Date Withdrawn: ________ Eligibility: Free___ Reduced___ Denied___ Tier I_____ Tier II____ Reason: _____________________________________________________________________________________________________ Temporary: Free_____ Reduced_____ Time Period: ______________________________(expires after _____ days) Determining Official’s Signature: _______________________________________________________________ Date: ______________ Confirming Official’s Signature: ________________________________________________________________ Date: ______________ Follow-up Official’s Signature: _________________________________________________________________ Date:______________

Household size	Yearly
1
2
3
4
5
6
7
8
Each additional person:

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.

OMB Disclosure Statement: According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0055. The time required to complete this information collection is estimated to average 16 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

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.

Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. “In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice).  Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).   USDA is an equal opportunity provider and employer.”

Part 1. All Household Members
Name of Enrolled Adult(s):
Names of Adult Participants (First, Middle Initial, Last)						CHECK IF NO INCOME
Part 2. Benefits: If any member of your household received [State SNAP], [FDPIR], [State SSI] or [Medicaid], 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. Total Household Gross Income—You must tell us how much and how often
A. Name (List only the participant(s), spouse and dependent children of participant(s))		B. Gross income and how often it was received
		1. Earnings from work before deductions	2. Welfare, child support, alimony	3. Pensions, retirement, Social Security, SSI, VA benefits	4. All Other Income
(Example) Jane Smith		$200/weekly_____	$150/twice a month_	$100/monthly_____	$______/________
		$______/________	$______/________	$______/________	$______/_______
		$______/________	$______/________	$______/________	$______/_______
		$______/________	$______/________	$______/________	$______/_______
		$______/________	$______/________	$______/________	$______/_______
Part 4. Signature and Last Four Digits of Social Security Number 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 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: ________________________________________ Date: ____________________________ Address: ___________________________________________ Phone Number: _______________________ City:_______________________________________________ State: ________________ Zip Code: ________________ Last four digits of Social Security Number: _* _* _* - _* _* - __ __ __ __  I do not have a Social Security Number
Part 5. Participant’s ethnic and racial identities (optional)
Mark one ethnic identity:	Mark one or more racial identities:
 Hispanic or Latino  Not Hispanic or Latino	Asian  American Indian or Alaska Native White  Native Hawaiian or Other Pacific Islander 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

Total Income: ____________ Per:  Week,  Every 2 Weeks,  Twice A Month,  Month,  Year Household size: _________

Categorical Eligibility: ___ Date Withdrawn: ________ Eligibility: Free___ Reduced___ Denied___ Tier I_____ Tier II____

Reason: _____________________________________________________________________________________________________

Temporary: Free_____ Reduced_____ Time Period: ______________________________(expires after _____ days)

Determining Official’s Signature: _______________________________________________________________ Date: ______________

Confirming Official’s Signature: ________________________________________________________________ Date: ______________

Follow-up Official’s Signature: _________________________________________________________________ Date:______________

Household size	Yearly
1
2
3
4
5
6
7
8
Each additional person:

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.

OMB Disclosure Statement: According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0055. The time required to complete this information collection is estimated to average16 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

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 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.

Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. “In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice).  Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).   USDA is an equal opportunity provider and employer.”

May 2011 CACFP Meal Benefit Income Eligibility

Child Care Form

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