CACFP Meal Benefit Income Eligibility Form

Complete one application per household

STEP 1

List ALL children or adults in day care (if more spaces are required for additional names, attach another sheet of paper)
Children in Foster care and children who meet the definition of Homeless, Migrant or Runaway are eligible for free meals. Children in Head Start are eligible for free meals if an approved head start application or statement of enrollment is attached.


STEP 2

List the following assistance programs any household member participates in - for child care: SNAP, TANF, or FDPIR, or for adult daycare: SNAP, FDPIR, SSI, or Medicaid

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. 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. Definition of Household Member: “Anyone who is living with you and shares income and expenses, even if not related.” STEP 4 Contact information

A. Child Income

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

B. All Other Household Members (Including yourself)

List all adult Household Members (including yourself) as well as any children not listed in STEP 1 even if they do not receive income. For each person listed, if they do receive income, report total gross income (before taxes) for each source in whole dollars. If they do not receive income from any source, you must write ‘0’ - do not leave blank. If you enter ‘0’, you are certifying that there is no income.
Check if no SSN Total Household Members (Children and Adults) Primary Wage Earner or other Adult Household Member

STEP 4

Contact information and adult signature. SUBMIT COMPLETED FORM TO THE DAY CARE 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.”
You will be directed to sign this form upon completion

OPTIONAL

Participant’s Ethnic and Racial Identities (Optional)
We are required to ask for information about the participant’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 eligibility for receiving meals during care.
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.
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
FAX: (202) 690-7442; or
EMAIL: program.intake@usda.gov.
This institution is an equal opportunity provider.
*Only use this address if you are filing a complaint of discrimination.