Income Eligibility Statement for CACFP revised 2024

Bright from the Start: Georgia Department of Early Care and Learning

CACFP Meal Benefit Income Eligibility Statement
Name of Child Care Center*
PART I: Child(ren) or Adult enrolled to receive day care
Child 1 Name: (Last, First and Middle Initial)
Child 2 Name: (Last, First and Middle Initial)
Child 3 Name: (Last, First and Middle Initial)
Child 4 Name: (Last, First and Middle Initial)
Child 5 Name: (Last, First and Middle Initial)
Child 1 Birthdate

MonthDayYear
Date
Child 2 Birthdate

MonthDayYear
Date
Child 3 Birthdate

MonthDayYear
Date
Child 4 Birthdate

MonthDayYear
Date
Child 5 Birthdate

MonthDayYear
Date
SNAP, TANF, or FDPIR case number, or Client ID number for children only. All the above, or SSI or Medicaid case number for Adults. Note: Do not use EBT numbers. Write case number and proceed to Part III.

Children in Head Start, foster care and children who meet the definition of migrant, runaway, or homeless are eligible for free meals. Check (✓) all that apply. (See definitions in FAQs)

Rows	Head Start	Foster Child	Migrant	Runaway	Homeless

PART II: Report income for ALL Household Members (Skip this step if participant is categorically eligible as documented in Part I

A. Child Income - Sometimes children in the household earn or receive income. Please indicate the TOTAL income received by child household members listed in PART I here.
Child Income/How often?
Child Income/How often?
B.Other Household Members. List all household members even if they do not receive income. Also, list the adult participant if he/she did not meet eligibility in Part I. For each Household Member listed, if they do receive income, report total gross income (before taxes) for each source in whole dollars (no cents) only. If they do not receive income from any source, write ‘0’. If you enter “0” or leave any field blank you are certifying (promising) there is no income to report.

Name of Other Household Members (First and Last)

Rows	Name of Other Household Members (First and Last)	1. Earnings from work before deductions/ How often?	2. Welfare, child support, alimony/ How often?	3. Social Security, Pensions, Retirement/ How often?	4. All other income/ How often?
1.
2.
3.
4.
5.

C.Total # of Household Members (Adults and Children) listed in Part I and Part II*
Social Security Number. If income is listed or completed in Part II, the adult completing the form must also list the last four digits of his or her Social Security Number or check the “I don’t have a Social Security Number” box below. (See Privacy Act Statement on next page). Failure to complete this section, if income is listed, will result in the denial of free or reduced eligibility.
Last four Digits of Adult's Social Security Number (XXX-XX-1234) completing this form.
I do not have a Social Security Number
Email
example@example.com
Part III: Enrollment Information - Children Only

My child is normally in attendance at the facility between the hours of 6am to 7pm.

Select the days your child will normally attend the center:*

Rows	Monday	Tuesday	Wednesday	Thursday	Friday
Days of Care

Select the meals your child will normally receive while in care: *

Rows	Breakfast	AM Snack	Lunch	PM Snack	Supper	Evening Snack
Meal Type

PART IV: Signature
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 purposefully give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted. This signature also acknowledges that the child(ren) or adult listed on the form in Part I are enrolled for care. If not completed fully and signed, the participant will be placed in the Paid category.
Signature*
Type First and Last Name
Date*

MonthDayYear
EX: 09/01/2021
Address*

Address

Street Address Line 2

CityState

Zip
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
*This application is a revision of USDA’s newly released meal benefit prototype and meets all legal requirements and reflect design best practices identified by USDA through focus testing and other research.
PART V: Participant’s Ethnic and Racial Identities (optional)
Check (✓) one ethnic identity

Hispanic/ LatinoNot Hispanic/ LatinoAsianWhiteBlack or African AmericanIndian or Alaska NativeHawaiian or other Pacific Islander
Dear Parent/Guardian: If your children qualify for free or reduced price meals, they may also be able to get free or low cost health insurance through Medicaid or the State Children's Health Insurance Program (SCHIP Children with health insurance are more likely to get regular health care and are less likely to become sick. Because health insurance is so important to children's well-being, the law allows us to tell Medicaid and SCHIP that your children are eligible for free or reduced price meals, unless you tell us not to. Medicaid and SCHIP only use the information to identify children who may be eligible for their programs. Program officials may contact you to offer to enroll your children in this health insurance program. Filling out the CACFP Meal Benefit Income Eligibility Forms does not automatically enroll your children in health insurance. If you do not want us to share your information with Medicaid or SCHIP, fill out the form below and send it with your Income Eligibility Form to [address] by [date]. (Sending in this form will not change whether your children get free or reduced-priced meals.)
No! I DO NOT want information from my CACFP Meal Benefit Income Eligibility Form shared with Medicaid or the State Children's Health Insurance Program.

No! I DO NOT want information from my XCACFP Meal Benefit Income Eligibility Form shared with Medicaid or the state children's Health Insurance Program.
If you checked no, fill out the form below.
Child's Name
Child's Name
Child's Name
Child's Name
Signature
Date

MonthDayYear
Date
Print Your Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Bright from the Start: Georgia Department of Early Care and Learning

PART IV: Signature