INSTRUCTIONS FOR
CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM
(CHILD CARE)
Follow these instructions, if your household gets SNAP, TANF or FDPIR:
Part 1: List all enrolled children and household members.
Part 2: List the eligibility number for any household members (including adults) receiving SNAP or TANF or FDPIR benefits. The SNAP or TANF number must be the 8 or 9 digit EDG# assigned by HHSC.
Part 3: Skip this part.
Part 4: Skip this part.
Part 5: Sign the form. The last four digits of a Social Security Number are not necessary.
Part 6: Answer this question if you choose.
Part 7: Answer this question if you choose.
If you are applying on behalf of a FOSTER CHILD, follow these instructions:
If all children you are applying for are foster children, or if you are only applying for benefits for the foster child:
Part 1: List all foster children. Check the box indicating that the child is a foster child.
Part 2: Skip this part.
Part 3: Skip this part.
Part 4: Skip this part.
Part 5: Sign the form. A Social Security Number is not necessary.
Part 6: Answer this question if you choose.
Part 7: Answer this question if you choose.
If some of the children in the household are foster children.
Part 1: List all enrolled children and household members. For any people, including children, with no income, you must check the "No Income Box." Check the box if the child is a foster child.
Part 2: If the household does not have an eligibility number, skip this part.
Part 3: Applies only to parents/guardians of children in Tier II Day Care Homes. Sponsors must provide the List of Eligible Federal/State Funded Programs (H1660), with this form to households with children enrolled in Tier II Day Care Homes. Parents/Guardians can enter the program name and number as applicable.
Part 4: Follow these instructions to report total household income from this month or last month.
Column A - Name: List only the first and last name of each person living in your household who share income and expenses, related or not (such as grandparents, other relatives, or friends who live with you) with income. Include yourself and all children living with you. Attach another sheet of paper if you need to.
Column B - Gross Income and How Often it was Received: For each household member, list each type of income received for the month. You must tell us how often the money is received – weekly, every other week, twice a month, or monthly.
Box 1: List the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your stub or your boss can tell you.
Box 2: List the amount each person got from the month from welfare, child support, alimony.
Box 3: List retirement, Social Security, Supplemental Security Income (SSI), Veteran's (VA) benefits, disability benefits.
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Center Name is Retta Christian Learning Center:
Enrollment
Date of Current CACFP Enrollment:
*
-
Month
-
Day
Year
Date
Date of Withdrawal:
-
Month
-
Day
Year
Date
Child Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Days In Care
*
MON
TUE
WED
THURS
FRI
Meals Attending
*
BREAKFAST
AM SNACK
LUNCH
PM SNACK
Parent/Guardian Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City, ST, Zip
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Arrive
*
630-830 AM
830-1030 AM
Depart
*
300-430 PM
430-600 PM
Cell Phone
*
Format: (000) 000-0000.
Work Phone
*
Format: (000) 000-0000.
Email
*
example@example.com
Race
*
White
Black
Asian
Native American Indian
Alaska Native
Hawaiian/Pacific Islander
Other
Ethnicity
*
Hispanic
Non-Hispanic
THIS SECTION MUST BE COMPLETED FOR INFANTS UNDER 12 MONTHS OF AGE
Under the regulations of the USDA CACFP, this center is required to offer an iron-fortified formula of the center's choice. This center offers this iron-fortified formula: You may accept or decline the offered formula. Please select your preferences below:
I accept the formula offered by this center.
I decline the formula offered by this center and will bring expressed breast milk.
I decline the formula offered by this center and will bring this formula: This formula is:
I decline the formula offered by this center and will bring this formula:
Iron-fortified
Low-iron
Iron free
(If this formula is low-iron or iron free, I understand a medical statement must be provided to the center.)
Under the regulations of the USDA CACFP, this center is required to offer solid foods such as iron-fortified infant cereal, vegetables, fruits, meat/meat alternates and crackers when an infant is developmentally ready to accept these components as recommended by the American Academy of Pediatrics and as specified in the Infant Meal Pattern. Please select your preferences below:
I accept the solid foods offered by this center
I decline the solid foods offered by this center and will bring the solid foods for my infant
This center is required to update the feeding preferences of the infant as the situation changes as well as within one month of the infant changing age groups. Changes may include a change in the formula or foods. Please update any changes below (example: change formula to IF Similac; begin feeding IF infant cereal):
New Instructions:
Today's Date:
-
Month
-
Day
Year
Date
Infant Age
0-5 mos
6-11 mos
Dear parent, because your day care provider cares about good nutrition, they have chosen the benefits of the Child and Adult Care Food Program (CACFP). This program is sponsored by Under the regulations of the CACFP, your provider may not charge you separate fees for meals, nor may you be asked to provide food for your child for those meals claimed under the program. 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 based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866)632-9992. Submit your completed form or letter 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; fax: 202-690-7442; or email: program.intake@usda.gov. This institution is an equal opportunity provider and employer.
Signature of Parent/Guardian
*
Date of Signature
*
-
Month
-
Day
Year
Date
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CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)
Part 1. All Household Members
Name of Enrolled Child(ren):
*
Part 1. All Household Members
*
Rows
Names of all household members (First, Middle Initial, Last)
CHECK IF A FOSTER CHILD (THE LEGAL RESPONSIBILITY OF A WELFARE AGENCY OR COURT) * IF ALL CHILDREN LISTED BELOW ARE FOSTER CHILDREN, SKIP TO PART 5 TO SIGN THIS FORM.
Type an "X" to check if no income
1
2
3
4
5
6
7
Part 2. Benefits: If any member of your household receives SNAP, TANF, or FDPIR, provide the name and eligibility number for the person who receives benefits. If no one receives these benefits, skip to part 3.
NAME:
ELIGIBILITY NUMBER:
Part 3. (Applies only to parents/guardians with children enrolled in a day care home) If any member of your household receives benefits listed on the enclosed List of Eligible Federal/State Funded Programs (H1660), provide the name of the program and eligibility number:
NAME:
ELIGIBILITY NUMBER:
Check here if no eligibility number
Part 4. Total Household Gross Income-You must tell us how much and how often
*
Rows
Name: List only members with an income (ex: Mary Ann)
1. Earnings from work before deductions (ex: $200 weekly)
2. Welfare, child support, alimony ($150 bi weekly)
3. Pensions, retirement, Social Security, SSI, VA benefits (ex $100 monthly)
4. All Other Income (ex: $200 bi-monthly)
Income 1
Income 2
Income 3
Income 4
Part 5. Signature and Last Four Digits of Social Security Number (Adult must sign)
An adult household member must sign this form. If Part 4 is completed, the adult signing the form must also list the last four digits of his or her Social Security Number or mark the "I do not have a Social Security Number" box. (See Privacy Act Statement on the next page.)
I certify that all information on this form is true and that all income is reported. I understand that the center or day care 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.
Sign here:
*
Print name:
*
Date:
*
-
Month
-
Day
Year
Date
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State:
*
Zip Code:
*
Phone Number:
*
Format: (000) 000-0000.
Last four digits of Social Security Number:
*
I do not have a Social Security Number
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CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)
Part 6. Participant's ethnic and racial identities (optional)
Mark one ethnic identity:
Hispanic or Latino
Not Hispanic or Latino
Mark one or more racial identities:
Asian
American Indian or Alaska Native
White
Native Hawaiian or Other Pacific Islander
Black or African American
Part 7. Sharing Information With Other Programs: OPTIONAL
The above information may be disclosed for the purpose of enrolling children in the Children's Health Insurance Program (CHIP). Parents/guardians are not required to consent to such disclosure and electing not to allow disclosure will not adversely affect a child's eligibility.
I do elect to allow my household information to be disclosed.
I do not elect to allow my household information to be disclosed.
Don't fill out this part. This is for official use only.
Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12
Total Income:
Per:
Week,
Every 2 Weeks,
Twice A Month,
Month,
Year
Household size:
Categorical Eligibility:
Date Withdrawn:
-
Month
-
Day
Year
Date
Eligibility:
Free
Reduced
Denied
Tier I
Tier II
Reason:
Determining Official's Signature:
Date:
-
Month
-
Day
Year
Date
Confirming Official's Signature:
Date:
-
Month
-
Day
Year
Date
Follow-up Official's Signature:
Date:
-
Month
-
Day
Year
Date
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 member who signs the application. 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), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) eligibility number for the participant or other (FDPIR) identifier 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-discrimination Statement:
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/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 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.
July 2022
CACFP Meal Benefit Income Eligibility
Child Care Form
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