Income Eligibility Statement for CACFP

Bright from the Start: Georgia Department of Early Care and Learning

CACFP Meal Benefit Income Eligibility Statement
Name of Child Care Center*
High Hope Academy
PART I: Child(ren) or Adult enrolled to receive day care
Child 1 Name: (Last, First and Middle Initial)*
Child 1 Birthdate*

MonthDayYear
Date
Child 2 Name: (Last, First and Middle Initial)
Child 2 Birthdate

MonthDayYear
Date
Child 3 Name: (Last, First and Middle Initial)
Child 3 Birthdate

MonthDayYear
Date
Child 4 Name: (Last, First and Middle Initial)
Child 4 Birthdate

MonthDayYear
Date
Child 5 Name: (Last, First and Middle Initial)
Child 5 Birthdate

MonthDayYear
Date
SNAP, TANF, or FDPIR 9 digit case number, or Client ID number for children only. All the above, or SSI or Medicaid case number for Adults. Note: Do not use EBT numbers. Write case number and proceed to Part III.

Children in Head Start, foster care and children who meet the definition of migrant, runaway, or homeless are eligible for free meals. Check (✓) all that apply.

	Head Start	Foster Child	Migrant	Runaway	Homeless
Child 1
Child 2
Child 3
Child 4
Child 5

PART II: Report Income for ALL Household Members

(Skip this step if participant is categorically eligible as documented in Part I)

A. Child Income - Sometimes children in the household earn or receive income. Please indicate the TOTAL income received by child household members listed in PART I here.
Total Child Income
How often?
B. Other Household Members.
- List all household members that were not previously listed on the form 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 field blank you are certifying (promising) there is no income to report.
- FOR ADULT DAYCARES: List the adult participant if he/she did not meet eligibility in Part I.

Name of Other Household Members (First and Last)

	Name of Other Household Members (First and Last) (Ex: Brown, Charlie)	1. Earnings from work before deductions/ How often? (Ex: $500/Weekly)	2. Welfare, child support, alimony/ How often? (Ex: $800/Monthly)	3. Social Security, Pensions, Retirement/ How often?(Ex: $400/Monthly)	4. All other income/ How often? (Ex: $300/Monthly)
1.
2.
3.
4.
5.

C. Total # of Household Members (Adults and Children) listed in Part I and Part II*
Social Security Number. If income is listed or completed in Part II, the adult completing the form must also list the last four digits of his or her Social Security Number or check the “I don’t have a Social Security Number” box below. (See Privacy Act Statement on next page). Failure to complete this section, if income is listed, will result in the denial of free or reduced eligibility.
Last four digits of Social Security Number *
(Ex: 1212)
Check if you do not have a Social Security Number

I do not have a Social Security Number
Part III: Enrollment Information: Children Only
Arrvial Time

Center Open Time

AM/PM Option
Pick Up Time

Center Closing Time

AM/PM Option
(✓) Check here if only before/after school care is provided.

Only enrolled in After School Care
Check the days your child will normally attend the center:*

MondayTuesdayWednesdayThursdayFriday
Check the meals your child will normally receive while in care:

BreakfastAM SnackLunchPM Snack
PART IV: Signature
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 purposefully give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted. This signature also acknowledges that the child(ren) or adult listed on the form in Part I are enrolled for care. If not completed fully and signed, the participant will be placed in the Paid category.
Print Name*
Signature*

Clear
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip
Cell Phone Number*
Please enter a valid phone number.
*This application is a revision of USDA’s newly released meal benefit prototype and meets all legal requirements and reflect design best practices identified by USDA through focus testing and other research.
PART V: Participant’s Ethnic and Racial Identities (optional)
Check (✓) one ethnic identity

Hispanic/ LatinoNot Hispanic/ Latino
Check (✓) one or more racial identity

AsianWhiteBlack or African AmericanIndian or Alaska NativeHawaiian or other Pacific Islander

SHARING INFORMATION WITH MEDICAID/SCHIP
Dear Parent/Guardian:

If your children qualify for free or reduced price meals, they may also be able to get free or low cost health insurance through Medicaid or the State Children's Health Insurance Program (SCHIP Children with health insurance are more likely to get regular health care and are less likely to become sick.

Because health insurance is so important to children's well-being, the law allows us to tell Medicaid and SCHIP that your children are eligible for free or reduced price meals, unless you tell us not to. Medicaid and SCHIP only use the information to identify children who may be eligible for their programs. Program officials may contact you to offer to enroll your children in this health insurance program. Filling out the CACFP Meal Benefit Income Eligibility Forms does not automatically enroll your children in health insurance.

If you do not want us to share your information with Medicaid or SCHIP, fill out the form below and send it with your Income Eligibility Form. (Sending in this form will not change whether your children get free or reduced-priced meals.)
Share information with Medicaid or SCHIP?*

YES!! I DO want information from my CACFP Meal Benefit Income Eligibility Form shared with Medicaid or the state children's Health Insurance Program.No! I DO NOT want information from my CACFP Meal Benefit Income Eligibility Form shared with Medicaid or the state children's Health Insurance Program.
Please fill out the form below.
Child 1 Name
Ex: First Last
Child 2 Name
Ex: First Last
Child 3 Name
Ex: First Last
Child 4 Name
Ex: First Last
Signature*

Clear
Date

MonthDayYear
Date
Print your name
Ex: First Last
Address
Ex: Street, Apt., State, Zip
Print Your Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Bright from the Start: Georgia Department of Early Care and Learning

PART IV: Signature

SHARING INFORMATION WITH MEDICAID/SCHIP