"Cacfp Meal Benefit Income Eligibility Form - Adult Care Food Program (Acfp)" - Florida

This "Cacfp Meal Benefit Income Eligibility Form - Adult Care Food Program (Acfp)" is a document issued by the Florida Department of Elder Affairs specifically for Florida residents with its latest version released on May 1, 2018.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Florida Department of Elder Affairs.

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CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Adult Care)
Part 1. All Household Members
Name of Enrolled Adult(s): (List name under Names of Adult Participants)
Names of Adult Participants
CHECK
(First, Middle Initial, Last)
IF NO INCOME
Part 2. Benefits: If any member of your household received [State SNAP], [FDPIR], [State SSI] or [Medicaid], 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:

TYPE OF BENEFIT (CHECK ONE):
SNAP
FDPIR
SSI
Medicaid
Part 3. Total Household Gross Income—You must tell us how much and how often
B. Gross income and how often it was received
A. Name
(List only the participant(s), spouse
1. Earnings from work
2. Welfare, child support,
3. Pensions, retirement,
4. All Other Income
and dependent children of
before deductions
alimony
Social Security, SSI, VA
participant(s))
benefits
(Example)
$200/weekly
$150/twice a month_
$100/monthly
$
/_
Jane Smith
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
Part 4. Signature and Last Four Digits of Social Security Number
An adult household member 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 mark the “I do not have a Social Security Number” box. (See
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 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.
Sign here:
Print name:
Date:
Address:
Phone Number:
City:_
State:
Zip Code:
 
Last four digits of Social Security Number: _* _* _* - _* _* -
I do not have a Social Security Number
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
May 2018
CACFP Meal Benefit Income Eligibility
Adult Care Form
Page 1 of 2
CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Adult Care)
Part 1. All Household Members
Name of Enrolled Adult(s): (List name under Names of Adult Participants)
Names of Adult Participants
CHECK
(First, Middle Initial, Last)
IF NO INCOME
Part 2. Benefits: If any member of your household received [State SNAP], [FDPIR], [State SSI] or [Medicaid], 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:

TYPE OF BENEFIT (CHECK ONE):
SNAP
FDPIR
SSI
Medicaid
Part 3. Total Household Gross Income—You must tell us how much and how often
B. Gross income and how often it was received
A. Name
(List only the participant(s), spouse
1. Earnings from work
2. Welfare, child support,
3. Pensions, retirement,
4. All Other Income
and dependent children of
before deductions
alimony
Social Security, SSI, VA
participant(s))
benefits
(Example)
$200/weekly
$150/twice a month_
$100/monthly
$
/_
Jane Smith
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
$_
/
Part 4. Signature and Last Four Digits of Social Security Number
An adult household member 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 mark the “I do not have a Social Security Number” box. (See
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 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.
Sign here:
Print name:
Date:
Address:
Phone Number:
City:_
State:
Zip Code:
 
Last four digits of Social Security Number: _* _* _* - _* _* -
I do not have a Social Security Number
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
May 2018
CACFP Meal Benefit Income Eligibility
Adult Care Form
Page 1 of 2
CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Adult Care)
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
 
 
 
 
Household size:
Total Income:
Per:
Week,
Every 2 Weeks,
Twice A Month,
Month,
Year
Categorical Eligibility:
Date Withdrawn:
Eligibility: Free
Reduced
Paid
Denied
Reason:
Determining Official’s Signature:
Date:
Household size
Yearly- Free
Yearly- Reduced-Price
$ 0 – $15,782
1
$ 15,783- $22,459
$ 0 – $21,398
2
$ 21,399- $30,451
$ 0 – $27,014
3
$ 27,015- $38,443
$ 0 – $32,630
4
$ 32,631- $46,435
$ 0 – $38,246
5
$ 38,247- $54,427
$ 0 – $43,862
6
$ 43,863 - $62,419
$ 0 – $49,478
7
$ 49,479- $70,411
$ 0 – $55,094
8
$ 55,095 - $78,403
Each additional person:
+ 5, 616
+ 7,992
The participant in the day care facility may qualify for free or reduced price meals if
your household income falls within the limits on this chart.
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 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.
“The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers,
Non-discrimination Statement:
employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion,
reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or if all or part of an
individual's income is derived from any public assistance program, or protected genetic information in employment or in any
program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employ ment
activities.)
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination
Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866)
632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your
completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400
Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov.
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at
(800) 877-8339; or (800) 845-6136 (in Spanish).
USDA is an equal opportunity provider and employer.”
May 2018
CACFP Meal Benefit Income Eligibility
Adult Care Form
Page 1 of 2
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