Child and Adult Care Food Program Income Eligibility Form

Guidestar Childcare Center
Location *
You MUST Save Progress or Submit before leaving this form or ALL entries will be lost.

Enrolled children

Enter the names of all children in your household enrolled in this center

Benefits

If any member of your household received SNAP, FDPIR, or TANF cash assistance, provide the name and case number for the person who receives benefits.

Homeless, migrant, runaway

If any child you are applying for is homeless, migrant, or a runaway, check the appropriate box and call your center director, homeless liaison, or migrant coordinator.
Child is
Child is
Child is

Total Household Gross Income - You must tell us how much and how often

List the names of all household members
Select yes in the foster child field to indicate that the member is a foster child (the legal responsibility of a welfare agency or court). If all children listed below are foster children, skip the income reporting and proceed to sign this form.
Select No income in the no income field to indicate that the member has no income.
 
For each household member with income, list each type of income received as of last month. You must tell us how often the money is received: yearly, monthly, weekly, twice a month, or every other week.
Foster child
No income
Foster child
No income
Foster child
No income
Foster child
No income
Foster child
No income
Foster child
No income
Foster child
No income
Foster child
No income
Foster child
No income
Foster child
No income

Signature and Last Four Digits of Social Security Number (Adult must sign)

An adult household member must sign this form. If income is reported, 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.

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.
 
I certify that my electronic signature entered below is legally binding.
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Enter primary phone number as 10 digits with no other characters
SSN *
 

Participant’s ethnic and racial identities (optional)

Check one ethnic identity and one or more racial identities.
Ethnic identity
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, 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) case 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.
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, religious creed, disability, age, political beliefs, 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 complaint of discrimination, 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:
(1) mail: U.S. Department of Agriculture,
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or
(3) email: program.intake@usda.gov.
This institution is an equal opportunity provider

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
Income frequency
Categorical eligibility
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Eligibility
Temporary
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