"Meal Benefit Income Eligibility Form (Adult Care) - Child and Adult Care Food Program"

Meal Benefit Income Eligibility Form (Adult Care) - Child and Adult Care Food Program is a 2-page legal document that was released by the U.S. Department of Agriculture - Food and Nutrition Service and used nation-wide.

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CHILD AND ADULT CARE FOOD PROGRAM
MEAL BENEFIT INCOME ELIGIBILITY FORM (Adult Care)
FISCAL YEAR 2019
CACFP M
B
I
E
L
EAL
ENEFIT
NCOME
LIGIBILITY
ETTER
(A
C
C
)
DULT
ARE
ENTER
Dear Participant/Guardian:
The CACFP offers meal reimbursements to adult day care centers which provide structured comprehensive services to
nonresidential adults who are functionally impaired, or age 60 and older. By completing the attached Meal Benefit Income
Eligibility Form, the centers will be able to receive reimbursement, which is based on the number of enrolled participants
that are eligible for free or reduced price meals. A household with income less than or equal to the income chart for
reduced-priced meals below is eligible for free or reduced-priced meals. In order for the center to be considered eligible for
free and reduced-price meals based on income, an application must contain complete documentation of eligibility
information including total current household income, names of all household members, the social security numbers of the
household member who signs the application, or the word “None,” and the date and signature of the adult household
member who completed the application.
This information will be kept confidential and only available to staff directly
connected with administering the CACFP. The participant in the adult day care center may qualify for free or reduced price
meals if your household income falls within the limits on this chart:
Household size
Yearly
1
$22,459
2
$30,451
3
$38,443
$46,435
4
5
$54,427
6
$62,419
7
$70,411
$78,403
8
Each additional person:
$ 7,992
If an adult participant is a member of a SNAP (formerly food stamps) or FDPIR household or is a SSI or Medicaid
participant, the adult participant is automatically eligible to receive free Program meal benefits, subject to the completion of
the application. Participants having family members who become unemployed are eligible for free or reduced-price meals
during the period of unemployment; provided that the loss of income causes the family income during the period of
unemployment to be eligible for those meals.
Privacy Act Statement (This explains how we will use the information you give us): The Richard B. Russell National
School Lunch Act requires the information on this application. You do not have to provide 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 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.
Non-discrimination Statement (This explains what to do if you believe you have been treated unfairly): “In
accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating
on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA,
Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866)
632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the
Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and
employer.”
PLEASE COMPLETE THE REVERSE SIDE OF THIS FORM
FY 2019 - CACFP Meal Benefit Income Eligibility Form-Adult Care
CHILD AND ADULT CARE FOOD PROGRAM
MEAL BENEFIT INCOME ELIGIBILITY FORM (Adult Care)
FISCAL YEAR 2019
CACFP M
B
I
E
L
EAL
ENEFIT
NCOME
LIGIBILITY
ETTER
(A
C
C
)
DULT
ARE
ENTER
Dear Participant/Guardian:
The CACFP offers meal reimbursements to adult day care centers which provide structured comprehensive services to
nonresidential adults who are functionally impaired, or age 60 and older. By completing the attached Meal Benefit Income
Eligibility Form, the centers will be able to receive reimbursement, which is based on the number of enrolled participants
that are eligible for free or reduced price meals. A household with income less than or equal to the income chart for
reduced-priced meals below is eligible for free or reduced-priced meals. In order for the center to be considered eligible for
free and reduced-price meals based on income, an application must contain complete documentation of eligibility
information including total current household income, names of all household members, the social security numbers of the
household member who signs the application, or the word “None,” and the date and signature of the adult household
member who completed the application.
This information will be kept confidential and only available to staff directly
connected with administering the CACFP. The participant in the adult day care center may qualify for free or reduced price
meals if your household income falls within the limits on this chart:
Household size
Yearly
1
$22,459
2
$30,451
3
$38,443
$46,435
4
5
$54,427
6
$62,419
7
$70,411
$78,403
8
Each additional person:
$ 7,992
If an adult participant is a member of a SNAP (formerly food stamps) or FDPIR household or is a SSI or Medicaid
participant, the adult participant is automatically eligible to receive free Program meal benefits, subject to the completion of
the application. Participants having family members who become unemployed are eligible for free or reduced-price meals
during the period of unemployment; provided that the loss of income causes the family income during the period of
unemployment to be eligible for those meals.
Privacy Act Statement (This explains how we will use the information you give us): The Richard B. Russell National
School Lunch Act requires the information on this application. You do not have to provide 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 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.
Non-discrimination Statement (This explains what to do if you believe you have been treated unfairly): “In
accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating
on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA,
Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866)
632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the
Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and
employer.”
PLEASE COMPLETE THE REVERSE SIDE OF THIS FORM
FY 2019 - CACFP Meal Benefit Income Eligibility Form-Adult Care
CHILD AND ADULT CARE FOOD PROGRAM
MEAL BENEFIT INCOME ELIGIBILITY FORM (Adult Care)
FISCAL YEAR 2019
Part 1. All Household Members - Name of Enrolled Adult(s):
DATE OF
BIRTH
CHECK
Names of Adult Participants (First, Middle Initial, Last)
(MM/DD/YY)
IF NO INCOME
Part 2. Benefits: If any member of your household received SNAP, FDPIR, State SSI or AHCCCS, provide the name and case number
for the person who receives benefits. If no one receives these benefits, skip to part 3.
NAME:_____________________________________________________________ CASE NUMBER: _________________________________
Part 3. Total Household Gross Income (income before any deductions) —You must tell us how much and how often
B. Gross income and how often it was received: identify weekly, every other week, monthly, yearly…
A. Name (List all people living in the
3. Pensions, retirement,
household, including spouse and/or
1. Earnings from work before
2. Welfare, child support,
Social Security, SSI, VA
children)
deductions
alimony
benefits
4. All Other Income
how much/how often
how much/how often
how much/how often
how much/how often
$______/________
$______/________
$______/________
$______/_______
$______/________
$______/________
$______/________
$______/_______
$______/________
$______/________
$______/________
$______/_______
$______/________
$______/________
$______/________
$______/_______
Part 4. Signature and Last Four Digits of Social Security Number: A responsible adult must sign this form. If Part 3 is completed,
the adult signing the form must also list the last four digits of his or her Social Security Number or write the word None if the
signer doesn’t have a Social Security Number. (See Privacy Act Statement on the back of this page.)
I certify that all information on this form is true and that all income is reported. I understand that the center 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.
Sign here: __________________________________________ Print name: ___________________________________ Date: ________________
Address: ___________________________________________ Phone Number: _______________________
City:_______________________________________________ State: __________________
Zip Code: ________________
Last four digits of Social Security Number: _* _* _* - _* _* - _____ _____ _____ _____
If no SSN, write the word “None.” __________________
Part 5. Participant’s ethnic and racial identities (optional):
Mark one ethnic identity:
Mark one or more racial identities:
 Hispanic or Latino
 Asian
 American Indian or Alaska Native
 Not Hispanic or Latino
 White
 Native Hawaiian or Other Pacific Islander
 Black or African American
Don’t fill out this part. This is for official use only:
Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12
Total Income: _________________ Per:  Week,  Every 2 Weeks,  Twice A Month,  Month,  Year
Household size: _________
Categorical/Income Eligibility:
Free_________ Reduced_________ Paid_________
Determining Official’s Signature: _______________________________________________________________ Date: ______________
Confirming Official’s Signature: ________________________________________________________________ Date: ______________
FY 2019 - CACFP Meal Benefit Income Eligibility Form-Adult Care
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