Iowa Eligibility Application

If Part 4 is completed, the adult signing the form must provide the last 4 digits of his or her Social Security Number or mark the "I do not have a Social Security

Number" box. For further information refer to the Privacy Act Statement in the parent letter.

Part 5. Certification and Signature. REQUIRED OF ALL APPLICANTS.

I certify (promise) that all information on this application is true and that all income is reported if required. I understand that I will receive benefits from Federal

funds based on the information I give. I understand that officials may verify (check) the information. I understand that if I purposely give false information, my

children may lose meal/milk benefits, and I may be prosecuted.

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 submit all needed information, we cannot approve your child for free or reduced price meals. 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 of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Family Investment Program (FIP) 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 if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. 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.

Persons who are engaged in farming or who operate other types of private businesses may experience variations in cash flow or monthly income throughout the year. These persons may use their income tax records from the preceding calendar year as a basis for applying for meal benefits. The income to be reported is income derived from the business venture less operating costs incurred in the generation of that income. Deductions for personal expenses such as medical expenses and other non-business deductions are not allowed in reducing gross business income. If you have additional income from other kinds of employment, this income must be treated as separate and apart from the income generated from your business venture. USDA DOES NOT recognize income the same way as IRS. USDA does not permit a loss from a business venture to off-set earnings from wages or salary. Though your business may have suffered a net operational loss, for purposes of this Application, it is not possible to have a negative income. The least self-employed income possible is zero (no income For example, if you operated a business at a net loss but held another job where you received wages, your income for purposes of applying for Tier 1 meals would be the income from your wages only. The loss from the business cannot be deducted from the amount of the income earned in the other job. A prior year loss from farming or other private business operation cannot be used to reduce the current year net income for determining free and reduced-price eligibility. Wages paid to a spouse or other family or household member in the operation of a farm or private business must be shown as household income in Part 5 of this Application. Income from private business operations is to be taken from your most recent U.S. Individual Income Tax Return - Form 1040 or 1040- SR including Schedule 1 (Additional Income and Adjustments to Income Complete the identified lines from Form 1040 or Form 1040- SR and Schedule 1.

*The least income possible is zero (a negative number cannot be reported).

*Enter amount in the “All other Income” column in Part 4 on the front of this Application.

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 USDA’s 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/ad-3027.pdf, from any USDA office, by calling

(866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s 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:

1. mail:

U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW

Washington, D.C. 20250-9410; or

2. fax:

(833) 256-1665 or (202) 690-7442; or

3. email:

Program.Intake@usda.gov

This institution is an equal opportunity provider.

*Do not mail applications to this address, only complaints of discrimination.

Iowa Non-Discrimination Statement: “It is the policy of this CNP provider not to discriminate on the basis of race, creed, color, sex,

sexual orientation, gender identity, national origin, disability, age, or religion in its programs, activities, or employment practices as

required by the Iowa Code section 216.6, 216.7, and 216.9. If you have questions or grievances related to compliance with this policy by

this CNP Provider, please contact the Iowa Civil Rights Commission, 6200 Park Ave., Suite 100, Des Moines, IA 50319-1004; phone

number 515- 281-4121, 800-457-4416; website: https://icrc.iowa.gov/.”

lowa Child and Adult Care Food Program Child Care Enrollment Form

CHILD & ADULT CARE FOOD PROGRAM

Your child is enrolled in a center that participates in the Child and Adult Care Food Program (CACFP By participating in this Program, the center follows federal meal pattern requirements and receives reimbursement to assist with food costs. The CACFP requires parents to provide specific enrollment information on an annual basis. This form will be placed in center files and treated as confidential information. Complete one form for all of your children who are enrolled at the center.

*Ethnicity (Select one and enter in the chart above): H=Hispanic or Latino or N=Not Hispanic or Latino

*Race (Select one or more and enter in the chart above): W=White, B=Black or African American, I=American Indian or Alaska Native, A=Asian, and P=Native Hawaiian or Other Pacific Islander. This

information is requested by the Federal Government in order to monitor compliance with Civil Rights law. You are not required to furnish this information, but are encouraged to do so. The law

requires that organizations may not discriminate on the basis of this information nor on whether you choose to furnish it.

Infants only (0 to 12 months):

As a participant in a USDA Child Nutrition Program, our center offers meals to children of all ages; you are not required to provide infant food or formula. Infant feeding is based on

Academy of Pediatrics nutrition guidelines. Infant foods served are appropriate for the age and developmental readiness of your infant.

Ask your center if you can breastfeed on-site. The parent may provide no more than one required meal component in order for the center to claim reimbursement for the meal. DHS licensed centers must follow CACFPinfantmeal pattern requirements regardless of who supplies the food. Your center can provide a copy of the CACFP infant meal pattern and a list of reimbursable foods upon request.

This institution is an equal opportunity provider.