CACFP Food Program Enrollment Packet PY 22-23 (Oct 4

Dear Parent/Guardian:

This center offers healthy meals to all enrolled children as part of our participation in the U.S. Department of Agriculture’s (USDA) Child and Adult Care Food Program (CACFP). The CACFP provides reimbursements for healthy meals and snacks served to children enrolled in child care. Please help us comply with the requirements of the CACFP by completing the attached Food Program Enrollment Packet, which includes Food Program Enrollment Form & Meal Benefit Income Eligibility Form
Center ID*
Center Name*
Daycare Phone No*
Please enter a valid phone number.

________________________________

Part IV. Household Income

If any member of your household receives income, please provide the name of the person receiving income, gross amount, and how often it is received. EVEN IF you feel your household income level will not qualify for the highest program benefits, please still provide it as our facility does receive some assistance, even for higher-income households. The CACFP helps reduce our costs for providing your child with the best nutrition possible. And, of course, your information is always kept 100% confidential.
Does anyone in the household receive income?*

YesNo
________________________________

Household Income Details

List only household members with income. First MI Last Name

Please provide amount and how often for each household member listed. Hourly Rate is not acceptable.

________________________________

Part V. Submitting Party Details

Please provide your details as the parent/guardian submitting this food program enrollment packet.
Your Name (First MI Last)
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number. This will not be shared with any other agency.
Last 4 of Social Security Number (If you do not have a SS#, enter 0000 and check the next box)*
No Social Security Number*

I do not have a Social Security Number

Part 5. Signature

I certify that all information on this form is true and that all income is reported. I understand that the center or daycare 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 purposely give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted.

The signature below must match your physical signature as much as possible.
Sign here*

Clear
Today's Date*

MonthDayYear
Date
For Determining Official Use Only
Household Size
Total Income:
$ Placeholder
Frequency

WeekEvery 2 WeeksTwice a MonthMonthYear
Categorical Eligibility
Eligibility

FreeReducedPaid
Reason
Determination Date

MonthDayYear
Date
Determining Official's Signature

Clear
Should be Empty:

	Names of ALL Household Members (First MI Last)	Check if NO INCOME	Check if FOSTER CHILD
1.
2.
3.
4.
5.
6.
7.

	Name of Household Member that receives income (First MI Last)	Amount of Pay $	How Often
1.
2.
3.

FOOD PROGRAM ENROLLMENT FORM