Appendix D - Household Income Statement Template

OMB #0584-0055
Expiration Date xx/xx/20xx

Appendix D. Household Income Statement Template

This information is being collected from households to confirm the household income eligibility
of children and adults that receive free or reduced-price meals through the Child and Adult Care
Food Program (CACFP). Section 17 of the National School Lunch Act, as amended (42 U.S.C.
1766), authorizes the CACFP. This collection is required to obtain or retain benefits and the
Food and Nutrition Service uses the information collected to enable institutions participating in
the CACFP to claim the reimbursement to which they are entitled by law. The information
collected is essential to conduct reviews that determine whether or not institutions are observing
the requirements of the Program established by regulations and statute. In addition, the
information collection is necessary for administering agencies to monitor these operations to
ensure compliance with legislative and regulatory requirements. Under the Privacy Act of 1974,
any personally identifying information obtained will be kept private to the extent of the law.
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
Office of Management and Budget (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 approximately 5 minutes (0.0835 hours) per response. The
burden consists of the time it takes for households to complete their application. Send comments
regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition
Services, Office of Policy Support, 1320 Braddock Place, Alexandria, VA 22314, ATTN: PRA
(0584-0055). Do not return a completed form to this address.

CACFP Meal Benefit Income Eligibility (Child Care)

Insert URL Here

Complete one application per household. Please use a pen (not a pencil).
List ALL children in day care (if more spaces are required for additional names, attach another sheet of paper)

Definition of Household
Member: “Anyone who is
living with you and shares
income and expenses,
even if not related.”

Child’s First Name

MI

Child’s Last Name

Foster Child Migrant

Children in Foster
care and children who
meet the definition of
Homeless, Migrant or
Runaway are eligible for
free meals.

STEP 2

Runaway Homeless Head Start

Check all that apply

STEP 1

OMB #0584-0055
Expiration Date xx/xx/20xx

APPLY ONLINE:

Do any household members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?

IF NO > Go to STEP 3

CASE NUMBER:

IF YES > Write case number here and proceed to STEP 4 (do not complete STEP 3)

Write only one case number in this space.

STEP 3

Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2)

Are you unsure what
income to include here?
Flip the page and review
the charts titled “Sources
of Income” for more
information.

Child Income

Weekly

Bi-Weekly Monthly Bi-Monthly

$

B. All Adult Household Members (Including yourself)
List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total gross income (before taxes)
for each source in whole dollars (no cents) only. If they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.
How often?

Name of Adult Household Members (First and last)

The “Sources of Income
for Children” chart will
help you with the Child
Income section.

The “Sources of Income
for Adults” chart will
help you with All Adult
Household Members
section.
Total Household Members (Children and Adults)

STEP 4

How often?

A. Child Income
Sometimes children in the household earn or receive income. Please include
the TOTAL income received by all Household Members listed in STEP 1 here.

Earnings from Work

Weekly

Bi-Weekly Monthly

Welfare/Child
Support/Alimony

2x Month

Pensions/Retirement/
How often?
Social Security/SSI/
VA Benefits
Weekly Bi-Weekly Monthly 2x Month

How often?
Weekly

Bi-Weekly Monthly

2x Month

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Last Four Digits of Social Security Number (SSN) of
Primary Wage Earner or other Adult Household Member

X

X

X

X

Check if no SSN

X

Contact information and adult signature. MAIL COMPLETED FORM TO YOUR SCHOOL AT:

“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that CACFP officials
may verify (check) the information. I am aware that if I purposely give false information, the participant/center may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.”

Print Name of Adult Signing the Form

Signature of Adult

Address

City

Today’s Date

State

Zip

Phone/Email

Source of Income for Children

Source of Income for Adults

Sources of Child Income

Examples

Earnings from work

• A child has a regular full or part-time job where they earn
a salary or wages

Social Security
- Disability Payments
- Survivors Benefits

• A child is blind or disabled and receives Social Security benefits
• A parent is disabled, retired, or deceased, and their child receives
Social Security benefits

Income from person outside of household

• A friend or extended family member reguarly gives
a child spending money

Income from any other source

• A child receives regular income from a private pension fund,
annuity, or trust

OPTIONAL

Public Assistance/Alimony/
Child Support

Pensions/Retirement/
All other sources of income

If you are in the U.S. Military:

•
•
•
•

• Basic pay and cash bonuses (do NOT
include combat pay, FSSA, or privatized
housing allowances)
• Allowances for off-base housing, food,
and clothing

•
•
•
•

• Social Security (including railroad
retirement and black lung benefits)
• Private Pensions or disability benefits
• Income from trusts or estates
• Annuities
• Investment income
• Earned interest
• Rental income
• Regular cash payments from
outside household

Earnings from Work
• Salary, wages, cash bonuses
• Net income from self-employment
(farm or business)

Unemployment benefits
Workers compensation
Supplemental Security Income (SSI)
Cash assistance from State or local
government
Alimony payments
Child support payments
Veterans benefits
Strike benefits

Children’s Ethnic and Racial Identities (Optional)

We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional
and does not affect your children’s eligibility for receiving meals during care.
Ethnicity (check one):

Hispanic or Latino

Race (check one or more):

Not Hispanic or Latino

American Indian or Alaskan Native

Asian

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, the funds your child
care center/provider receives may be impacted. You must include the last four digits of
the social security number of the adult household member who signs the application. The
last four digits of 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 or other FDPIR identifier for your child 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 the meal reimbursement for
your child care center/provider. We MAY share your eligibility information with education,
health, and nutrition programs to help them evaluate, fund, or determine benefits for their
programs, auditors for program reviews, and law enforcement officials to help them look
into violations of program rules.

DO NOT FILL OUT

Black or African American

Native Hawaiian or Other Pacific Islander

White

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and
employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex,
disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who
require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the
Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the
Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.
gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the
form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
MAIL*:

U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410

FAX:
EMAIL:

(202) 690-7442; or
[email protected].

This institution is an equal opportunity provider.

*Only use this address if
you are filing a complaint
of discrimination.

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

How often?
Weekly

Bi-Weekly Monthly

2x Month

Eligibility

Household size

Free

Reduced

Denied

Categorial Eligibility

Determining Official’s Signature

Date

Confirming Official’s Signature

Date

Follow-up Official’s Signature

Date