Income Eligibility

INCOME ELIGIBILITY FORM FOR CHILD CARE CENTERS

To apply for free or reduced-price meal eligibility benefits for your child(ren), please fill out this form and return It to the child care center

PART 1: CHILD ENROLLED AT THE CHILD CARE CENTER

Complete information below for children enrolled at the center. If chlld(en) are receiving Supplemental Nutrition Assistance Program (SNAP) (formerty Food Stamp) or Temporary/ Assistance (formerly AFDC, now funded by TANF), complete Parts 1, 3, and 4 only. Complete Parts 1, 2, 3, and 4 If you did not provide a SNAP case number or Temporary Assistance case number for all of the children listed in Part 1.

Name(Required)

First Last

FOSTER CHILD(Required)

BIRTH DATE(Required)

SNAP CASE NUMBER(Required)

TEMPORARY ASSISTANCE CASE NUMBER(Required)

Name

First Last

FOSTER CHILD

BIRTH DATE

SNAP CASE NUMBER

TEMPORARY ASSISTANCE CASE NUMBER

Name

First Last

FOSTER CHILD

BIRTH DATE

SNAP CASE NUMBER

TEMPORARY ASSISTANCE CASE NUMBER

Name

First Last

FOSTER CHILD

BIRTH DATE

SNAP CASE NUMBER

TEMPORARY ASSISTANCE CASE NUMBER

PART - 2: HOUSEHOLD AND INCOME INFORMATION

List all members of the household not Including the chlidren listed in Part 1. Indicate source and amount of current monthly gross income for all members of the household before deductions, such as taxes and social security. Where there are wage earners and self-employed adults, the income of the wage earner cannot be offset by the business losses of the self-employed adult. If last month's income does not accurately reflect your circumstances, you may provide a projection of your current annual income. Irregular self-employed income may be averaged over the prior 12 months. Foster children may be eligible regardless of household Income. Contact the center for more information.

INCOME BASED ON(Required)

HOUSEHOLD MEMBERS(Required)

HOUSEHOLD MEMBERS

GROSS WAGES

WELFARE, CHILD SUPPORT, ALIMONY

PENSIONS, RETIREMENT, SOCIAL. SECURITY

OTHER

PART 3: RACIAL ETHNIC INFORMATION

(You are not required to answer this section)

Are you of Hispanic or Latino origin?

YES

What is your race? (Select one or more)

AMERICAN INDIAN OR ALASKA NATIVE

ASIAN

BLACK OR AFRICAN AMERICAN

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

WHITE

PART 4: SIGNATURE

1 hereby certify that all information provided is correct. I underestand that this Information Is being given In connection with the recaipt of federal funds, that Institution officials may verify information, and that deliberate misrepresentation may subject me to prosecution under applicable state and federal laws.

SIGNATURE OF ADULT FAMILY MEMBER(Required)

SOCIAL SECURITY NUMBER (LAST 4 DIGITS ONLY)(Required)

Date

PRINTED NAME OF ADULT

Address

Street Address City State ZIP Code

PHONE NUMBER(Required)

PARENT/GUARDIAN'S EMAIL ADDRESS

Section 9 of the National School Lunch Act requires that, unless your children's SNAP or Temporary Assistance case number is provided, you must include the last four digits of a social security number of the adult household member signing the application or indicate that the household member signing the application does not possess a social security number. Provision of the last four digits of a social security number is not mandatory, but if the last four digits of a social security number are not provided or an indication is not made that the signer has none, the application cannot be approved. The social security number may be used to identify the household member in carrying out efforts to verify the accuracy of Information stated on the application. These verification efforts may be carried out through program reviews and Investigations, and may Include contacting employers to determine income, contacting a SNAP or welfare office to determine current certification for receipt of SNAP or Temporary Assistance benefits, contacting the State employment security office to determine the amount of benefits received and checking the documentation produced by the household member to provide the amount of income received. These efforts may result in a loss or reduction of benefits, administrative claims, or legal actions If Incorrect information is reported.

FOR CENTER USE ONLY

TOTAL HOUSEHOLD SIZE:

INCOME:

INCOME BASED ON (CHECK ONE):

YEAR

MONTH

2XA MONTH

EVERY 2 WEEKS

WEEKLY

SNAP (Food Stamp)

TEMPORARY ASSISTANCE

Eligibility Determination:

Free

Reduced

Paid

SIGNATURE OF CENTER REPRESENTATIVE

DATE