"Child and Adult Care Food Program Meal Benefit Income Eligibility Application Form" - Arizona

Child and Adult Care Food Program Meal Benefit Income Eligibility Application Form is a legal document that was released by the Arizona Department of Education - a government authority operating within Arizona.

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2018-2019 Child and Adult Care Food Program Meal Benefit Income Eligibility Application
Complete one application per household. Please use a pen (not a pencil).
(Child Care Centers)
STEP 1
List ALL Household Members who are infants, children, and students up to and including age 18 (if more spaces are required for additional names, attach another sheet of paper)
Homeless,
Enrolled?
Foster
Migrant,
Child’s First Name
MI
Child’s Last Name
Age
Definition of Household
Yes
No
Runaway
Child
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. Read
How to Apply for Free and
Reduced Price School
Meals for more information.
STEP 2
Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?
> Go to STEP 3.
Case Number:
If NO
If YES >
Write a case number here then go to STEP 4 (Do not complete STEP 3)
Write only one case number in this space.
Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2)
How often?
A. Child Income
Weekly Bi-Weekly 2x Month
Monthly
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 Adult Household Members (including yourself)
Are you unsure what
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.
income to include here?
How often?
How often?
How often?
Flip the page and review
Public Assistance/
Pensions/Retirement/
Earnings from Work
Weekly
Bi-Weekly 2x Month Monthly
Weekly Bi-Weekly
2x Month Monthly
Weekly
Bi-Weekly 2x Month
Monthly
the charts titled “Sources
Child Support/Alimony
All Other Income
Name of Adult Household Members (First and Last)
of Income” for more
information.
$
$
$
The “Sources of Income
$
$
$
for Children” chart will
help you with the Child
Income section.
$
$
$
The “Sources of Income
for Adults” chart will help
$
$
$
you with the All Adult
Household Members
$
$
$
section.
Last Four Digits of Social Security Number (SSN) of
Total Household Members
X
X
X X
X
Check if no SSN
(Children and Adults)
Primary Wage Earner or Other Adult Household Member
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 determining officials may verify (check) the information. I am aware that if I purposely
give false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.”
Street Address (if available)
Apt #
City
State
Zip
Daytime Phone and Email (optional)
Printed name of adult signing the form
Signature of adult
Today’s date
2018-2019 Child and Adult Care Food Program Meal Benefit Income Eligibility Application
Complete one application per household. Please use a pen (not a pencil).
(Child Care Centers)
STEP 1
List ALL Household Members who are infants, children, and students up to and including age 18 (if more spaces are required for additional names, attach another sheet of paper)
Homeless,
Enrolled?
Foster
Migrant,
Child’s First Name
MI
Child’s Last Name
Age
Definition of Household
Yes
No
Runaway
Child
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. Read
How to Apply for Free and
Reduced Price School
Meals for more information.
STEP 2
Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?
> Go to STEP 3.
Case Number:
If NO
If YES >
Write a case number here then go to STEP 4 (Do not complete STEP 3)
Write only one case number in this space.
Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2)
How often?
A. Child Income
Weekly Bi-Weekly 2x Month
Monthly
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 Adult Household Members (including yourself)
Are you unsure what
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.
income to include here?
How often?
How often?
How often?
Flip the page and review
Public Assistance/
Pensions/Retirement/
Earnings from Work
Weekly
Bi-Weekly 2x Month Monthly
Weekly Bi-Weekly
2x Month Monthly
Weekly
Bi-Weekly 2x Month
Monthly
the charts titled “Sources
Child Support/Alimony
All Other Income
Name of Adult Household Members (First and Last)
of Income” for more
information.
$
$
$
The “Sources of Income
$
$
$
for Children” chart will
help you with the Child
Income section.
$
$
$
The “Sources of Income
for Adults” chart will help
$
$
$
you with the All Adult
Household Members
$
$
$
section.
Last Four Digits of Social Security Number (SSN) of
Total Household Members
X
X
X X
X
Check if no SSN
(Children and Adults)
Primary Wage Earner or Other Adult Household Member
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 determining officials may verify (check) the information. I am aware that if I purposely
give false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.”
Street Address (if available)
Apt #
City
State
Zip
Daytime Phone and Email (optional)
Printed name of adult signing the form
Signature of adult
Today’s date
INSTRUCTIONS
Sources of Income
Sources of Income for Children
Sources of Income for Adults
Pensions / Retirement /
Public Assistance /
Sources of Child Income
Earnings from Work
Example(s)
All Other Income
Alimony / Child Support
- A child has a regular full or part-time job
Unemployment benefits
-
- Salary, wages, cash
- Earnings from work
-
Social Security
where they earn a salary or wages
-
(including railroad
Worker’s compensation
bonuses
- Net income from self-
-
retirement and black lung
Supplemental Security
- A child is blind or disabled and receives Social
- Social Security
benefits)
employment (farm or
Income (SSI)
Security benefits
- Disability Payments
-
Private pensions or
business)
-
Cash assistance from
- Survivor’s Benefits
- A Parent is disabled, retired, or deceased, and
disability benefits
State or local
their child receives Social Security benefits
-
Regular income from
government
If you are in the U.S. Military:
trusts or estates
-Income from person outside the household
- A friend or extended family member
-
Alimony payments
-
Annuities
regularly gives a child spending money
-
- Basic pay and cash bonuses
Child support payments
-
Veteran’s benefits
Investment income
-
(do NOT include combat pay,
-
Earned interest
Strike benefits
-
FSSA or privatized housing
-
-Income from any other source
- A child receives regular income from a
Rental income
allowances)
private pension fund, annuity, or trust
-
Regular cash payments
- Allowances for off-base
from outside household
housing, food and clothing
OPTIONAL
Children's Racial and Ethnic Identities
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 free or reduced price meals.
Ethnicity (check one):
Hispanic or Latino
Not Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Asian
Race (check one or more):
American Indian or Alaskan Native
Black or African American
White
Persons with disabilities who require alternative means of communication for program information (e.g. Braille,
The Richard B. Russell National School Lunch Act requires the information on this application. You do
large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they
not have to give the information, but if you do not, we cannot approve your child for free or reduced price
applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA
meals. You must include the last four digits of the social security number of the adult household member who
through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made
signs the application. The last four digits of the social security number is not required when you apply on
available in languages other than English.
behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form,
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
(AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or
member signing the application does not have a social security number. We will use your information to
write a letter addressed to USDA and provide in the letter all of the information requested in the form. To
determine if your child is eligible for free or reduced price meals, and for administration and enforcement of
request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
the lunch and breakfast programs. We MAY share your eligibility information with education, health, and
U.S. Department of Agriculture
mail:
nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for
Office of the Assistant Secretary for Civil
program reviews, and law enforcement officials to help them look into violations of program rules.
Rights 1400 Independence Avenue, SW
Washington, D.C. 20250-9410
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
fax:
(202) 690-7442; or
administering USDA programs are prohibited from discriminating based on race, color, national origin, sex,
email:
program.intake@usda.gov.
disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or
This institution is an equal opportunity provider.
funded by USDA.
Do not fill out
For Official Use Only
Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24 Monthly x 12
Eligibility:
How often?
Total Income
Free
Reduced
Paid
Weekly
Bi-Weekly
2x Month
Monthly
Household Size
Categorical Eligibility
Confirming Official’s Signature
Date
Date
Determining Official’s Signature
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