CACFP Meal Benefit Income Eligibility Statement

PART I: Child(ren) or Adult enrolled to receive day care

Name(Required)
Birth Date:(Required)
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 (v) all that apply. (See definitions in FAQs)
Children in(Required)
Name
Birth 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 (v) all that apply. (See definitions in FAQs)
Children in(Required)
Name
Birth 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 (v) all that apply. (See definitions in FAQs)
Children in(Required)
Name
Birth 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 (v) all that apply. (See definitions in FAQs)
Children in(Required)

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

Are you unsure what income to include here? Flip the page and review the charts titled "Sources of Income" for more information.
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 | here.
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 'O'. If you enter "O" or leave any field blank you are certifying (promising) there is no income to report.
Name of Other Household Members (First and Last)
Name of Other Household Members (First and Last)
Name of Other Household Members (First and Last)
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.
I do not have a Social Security Number

PART III: Enrollment Information:

Children Only
My child is normally in attendance at the facility between the hours of(Required)
:
To(Required)
:
Check here if only before/after school care is provided.(Required)
Circle the days your child will normally attend the center:(Required)
Circle the meals your child will normally receive while in care:(Required)

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.
Clear Signature
MM slash DD slash YYYY
Address(Required)

*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:
Check one or more racial identities:

Official Use Only Section for Provider:

Annual Income Conversion: Weekly x 52, Every 2 weeks x 26, Twice a month x 24, Monthly x 12

Total income: ___________ Per: Household Size: ___________
Categorical Eligibility: check if applicable Eligibility:
Day Care Homes Only: check one
When more than one person is performing CACFP duties, there must be at least two signatures on this form: one signature from the Determining Official (the official who determined initial income classification) and one signature from the Confirming Official (the official who verified the form's accuracy).
Determining Official's Signature: ___________ Date: ___________
Confirming Official's Signature: ___________ Date: ___________
Follow Up Official's Signature: ___________ Date: ___________