PART 1: PARTICIPANT'S INFORMATION: ALL HOUSEHOLDS COMPLETE THIS PART.
(1) Print the name or names of the Participant(s) enrolled. (2) RACIAL/ETHNIC IDENTITY: COMPLETE THE RACIAL/ETHNIC IDENTITY. You are not required to answer this question to get meal benefits. This information will help ensure that everyone is treated fairly. (3) Start date, arrival and departure times, normal days and normal meals must be completed at the time of enrollment and/or renewal.
(1) List your current SNAP Case Number or your TANF Identification Number for the participant. DO NOT complete Part 2B, 2C or 2D. (2) An adult household member must sign the form in Part 3. PART 2B: ONLY HOUSEHOLDS ENROLLING A FOSTER CHILD: COMPLETE THIS PART AND PART 3. Refer to specific instructions indicated. List all foster children. Check the box indicating that the child is a foster child.
PART 2A: ONLY HOUSEHOLDS GETTING SNAP OR TANF BENEFITS: COMPLETE THIS PART AND PART 3.
(1) Write the names of everyone in your household. (2) Write the amount of income received last month for each household member (the amount before taxes or before anything else is taken out), and where it came from, such as earnings, welfare, pensions, and other income (refer to examples below for types of income to report If any amount last month was more or less than usual, write that person's usual income. An adult household member reporting total household income must sign the form and include the last four digits of give his/her Social Security Number in PART 3. Note to Center/Reviewer: If you are uncertain of how the family receives income (monthly, weekly, bl-weekly, annually) consider the income reported as the income for the month. If this is not workable, contact the family for clarification.
PART 2C: HOMELESS ENROLLEES ONLY. CHECK THE BOX AND COMPLETE PART 3. PART 2D: ANY HOUSEHOLD REPORTING TOTAL HOUSEHOLD INCOME. COMPLETE THIS PART AND PART 3.
Earnings From Employment: Wages/Salaries/Tips Strike Benefits Unemployment Compensation Worker's Compensation Net income from self-owned business or farm Welfare/Child Support/Alimony:
Public Assistance Payments Wellare Payments Alimony/Child Suppon
Pensions/Retirement/Social Security: Pensions, Supplemental Security Income Cash withdrawn from savings, Retirement Income Veteran's Payments Social Security Regular contributions from persons not living in the household Military Houschold: All cash income, including military housing uniform allowances Does not include in-kind" benefits NOT paid in cash (base housing, medical care, clothing, food, etc
Other Income: Disability Benefits Interest/Dividends Income from Estate/Trusts/lovestments Net Royahties/Assuities Net Rental Income Any Other Income Foster Child's Income: ONLY funds from welfare agency identified by category for personal use of child (clothing, school fees, etc, funds from child's family for personal use, and earnings from other sources (i.e., occasional or part-time employment) need to be included. DO NOT count funds from welfare agency for sheher, care, etc.
(1) All Income Eligibility Forms must have the signature of an adult household member. (2) The adult household member who signs the form must include the last four digits of his/her Social Security Number IF the participant is cligible for "free or reduced" based on household income. Section 9 of the National School Lunch Act requires that unless the participant's SNAP (food stamp), TANF case number is provided or the participant is a foster child or homeless, you must include the last four digits of the Social Security Number of the household member signing the statement, or an indication that the household member signing the statement does not possess a Social Security Number. Provision of the last 4 digits of the Social Security Number is not mandatory, but if a Social Security Number is not provided or an indication is not made that the adult household member signing the statement does not have one, the statement cannot be approved. The Social Security Number may be used to identify the household member in carrying out efforts to verify the correctness of information stated on the statement. These verification efforts may be carried out through program reviews, audits, and investigations and may include contacting employers to determine income, contacting a SNAP or TANF office to determine current certification for receipt of SNAP or TANF benefits, contacting the State Employment Security Office to determine the amount of benefits received and checking the documentation produced by the household member to prove the amount of income received. These efforts may result in a loss or reduction of benefits, administrative claims or legal action. If he/she does not have a Social Security Number, check the "I do not have a Social Security Number" box. (3)If you listed a SNAP or TANF case number or the participant is a Head Start, ECAP, Foster or Homeless child, the last four digits of a Social Security Number is not needed. SPONSOR USE ONLY - Eligibility Determination: To be completed by Child Care Representatives ONLY. (1) Complete total household income and size section. Compare total Income to Household Income Eligibility Guidelines. When household incomes are listed from different pay persons, you must convert all income to yearly income using the conversion table listed. Follow other instruction as indicated. (2) The review/effective date can be made retroactive back to the first day the child participates in the CACFP as long as it occurs in the same month this form is received. PRIVACY ACT STATEMENT: 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 nember who signs the application The SocialNumberis Securitynot required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP. i.e., Food Stamp Temporary Assistance for Needy Families (TANF) Program 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-DISCRIMIINATIOX STATEMENT: The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identify, religion, reprisal, and where applicable, political belicfs, marital status, familial or parental statis, sexual orientation, or all or of individual'sis orderived from any public assistance program, or protected genetic information in employment or in any or part an income conducted programactivityfunded theall byDepartment(Notprohibitedbaseswill toall apply programsand'or employment activities If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complain Form, found online at http://www.ascr.usda gov/complaint filing_ cust html or at any USDA office. or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form Send completedcomplaintformorlettertousbymailatU.S.ofAgriculure, yourDepartment Director,of Office1400 Adjudication,Avenue,D.C. IndependenceS.W.,20250-9410,690-7442 Washington,by fax (202) or email at program intake@usda gov. Individuals who are deal. hard of hearing. or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish) USD.4 is an equal opportunity provider and employer.
PART 3: CERTIFICATION - SIGNATURE AND SOCIAL SECURITY NUMBER: ALL HOUSEHOLDS COMPLETE THIS PART.