Utah CACFP Enrollment Form/ Free and Reduced-Price Income Application
Complete one application per household. In order to count as enrollment record, Steps 1 & 4 must be completed.
A. Child IncomeSometimes children in the household earn or receive income. Please include the TOTAL income received by all Household Members listed in STEP 1 here in whole dollars (no cents) only.
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 not 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" or leave any fields blank, you are certifying (promising) that there is no income to report.
"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 program officials may verify (check) the information. I am aware that ifI purposely give false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws."
Signature of Adult Signature*