Dear Parent/Guardian:
The Child and Adult Care Food Program (CACFP) makes good food a regular part of your child’s day care! Please fill out this CACFP Meal Benefit Income Eligibility form. It helps us determine if you and your child(ren) qualify for free or reduced-price meals. This form is required in order for us to provide healthy, tasty and free/low cost meals to your loved ones.
CBS Food Program appreciates the opportunity to serve you and your children. Please complete this whole form. Instructions for each page are availble to assist in completing this form.
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 ofthe 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, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.
Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDAʼs TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.
To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainantʼs name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:
Mail:U.S. Department of AgricultureOffice of the Assistant Secretary for Civil Rights1400 Independence Avenue, SWWashington, D.C.20250-9410
Fax: (833) 256-1665 or (202) 690-7442EMAIL: program.intake@usda.gov. *Only use this address if you are filing a complaint of discriminationCBS Food Program is an equal opportunity provider.
Instructions:
Dear Parent/Guardian,
CBS Food Program offers healthy meals and snacks to children as part of the Child and Adult Care Food Program (CACFP). Your child may be eligible for free or reduced-price meals, depending on your income. Your child qualifies if your household income is less than or equal to the limits on this chart.
You can find out if your child is eligible by filing out this CACFP Meal Benefit Income Elibility form. Please be sure to read the instructions carefully. Fill in all information we request. We can only approve completed forms.
If approved, your child will be eligible for the next 12 months. CBS Food Program reserves the right to verify the information provided in this form anytime during the year.
If you disagree with our determination, you have the right to appeal.
Thank you for taking the time to apply.
Sincerely,
CBS Food Program Staff
Fax: (833) 256-1665 or (202) 690-7442
EMAIL: program.intake@usda.gov. *Only use this address if you are filing a complaint of discrimination
CBS Food Program is an equal opportunity provider.
Children who get Child and Adult Care Food Program (CACFP) free or reduced-price meals may also qualify for low-cost health insurance through Medicaid or the State Children's Health Insurance Program (SCHIP).
We may share your child’s CACFP eligibility information with Medicaid or SCHIP, unless you tell us not to. Medicaid and SCHIP only use the information to find out if children are eligible for their programs. Their staff may contact you to offer to enroll your children in these health insurance programs.
If you do not want us to share your information with Medicaid or SCHIP, fill out this page. You should send this page with your CACFP Meal Benefit Income Eligibility form when you apply. Sending in this page will not change your child’s eligibility for free or reduced-price meals.
"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."