Child and Adult Care Food Program Meal Benefit Income Eligibility

Complete one application per household
Guidestar Childcare Center of the United States
Location *
You MUST Save Progress or Submit before leaving this form or ALL entries will be lost.

Step 1: List ALL children in day care

Definition of household member: "Anyone who is living with you and shares income and expenses, even if not related."
Children in foster care and children who meet the definition of homeless, migrant or runaway are eligible for free meals.
Foster child
Migrant
Runaway
Homeless
Head Start
Foster child
Migrant
Runaway
Homeless
Head Start
Foster child
Migrant
Runaway
Homeless
Head Start
Foster child
Migrant
Runaway
Homeless
Head Start
Foster child
Migrant
Runaway
Homeless
Head Start

Step 2: Do any household members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?

IF NO > Go to Step 3
IF YES > Write case number here and proceed to Step 4. (do not complete Step 3)
Write only one case number in this space

Step 3: Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2)

Are you unsure what income to include here? Scroll to the bottom and review the sections titled "Sources of Income" for more information.
 
A: Child income: Sometimes children in the household earn or receive income. Please include the TOTAL income received by all Household Members listed in STEP 1 here.
B. All other household members (including yourself): List all household members not listed in STEP 1 (including yourself) even if they do not receive income. 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 fields blank, you are certifying (promising) that there is no income to report.
 
Retirement: include pensions, Social Security, SSI, retirement, VA benefits
SSN last 4 digits: Last 4 digits of Social Security Number (SSN) of primary wage earner or other adult household member
SSN last 4 digits *
 

Step 4: Contact information and adult signature.

I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that CACFP officials may verify (check) the information. I am aware that if I purposely give false information, the participant/center may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.
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Enter primary phone number as 10 digits with no other characters

Office use only - this section will not be visible to applicants

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12
Categorical eligibility
Eligibility
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Children's ethnic and racial identities (optional)

We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children’s eligibility for receiving meals during care.
 
Check one ethnicity and one or more races.
Ethnicity
Race
Race
Race

Notices

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, the funds your child care center/provider receives may be impacted. 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) 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 the meal reimbursement for your child care center/provider. 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.
USDA Nondiscrimination Statement: In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are 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.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing, or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html 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:
Mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; Only use this address if you are filing a complaint of discrimination.
Fax: (202) 690-7442; or
Email: program.intake@usda.gov.

This institution is an equal opportunity provider.

Sources of income for children

Earnings from work
• A child has a regular full or part-time job where they earn a salary or wages
Social Security, disability payments, survivor’s benefits
• A child is blind or disabled and receives Social Security benefits
• A parent is disabled, retired, or deceased, and their child receives Social Security benefits
Income from person outside the household
• A friend or extended family member regularly gives a child spending money
Income from any other source
• A child receives regular income from a private pension fund, annuity, or trust

Sources of income for adults

Earnings from Work
• Salary, wages, cash bonuses
• Net income from self-employment (farm or business)
If you are in the U.S. Military:
• Basic pay and cash bonuses (do NOT include combat pay, FSSA or privatized housing allowances)
• Allowances for off-base housing, food and clothing
Public assistance, alimony, child support
• Unemployment benefits
• Worker’s compensation
• Supplemental Security Income (SSI)
• Cash assistance from state or local government
• Alimony payments
• Child support payments
• Veteran’s benefits
• Strike benefits
Pensions, retirement, all other income
• Social Security (including railroad retirement and black lung benefits)
• Private pensions or disability benefits
• Regular income from trusts or estates
• Annuities
• Investment income
• Earned interest
• Rental income
• Regular cash payments from outside household