"CACFP Meal Benefit Income Eligibility Statement Form" - Georgia (United States)

CACFP Meal Benefit Income Eligibility Statement Form is a legal document that was released by the Georgia Department of Early Care and Learning - a government authority operating within Georgia (United States).

Form Details:

  • Released on May 1, 2018;
  • The latest edition currently provided by the Georgia Department of Early Care and Learning;
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Download "CACFP Meal Benefit Income Eligibility Statement Form" - Georgia (United States)

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Bright from the Start: Georgia Department of Early Care and Learning
CACFP Meal Benefit Income Eligibility Statement*
PART I: Child(ren) or Adult enrolled to receive day care
Children in Head Start, foster care and children who meet the
SNAP, TANF, or FDPIR case number, or
definition of migrant, runaway, or homeless are eligible for
Client ID number for children only. All the
free meals. Check () all that apply.
(See definitions in FAQs)
above, or SSI or Medicaid case number for
Adults. Note: Do not use EBT numbers.
Foster
Head Start
Migrant
Runaway
Homeless
Child
Write case number and proceed to Part III.
Name: (Last, First and Middle Initial)
PART II: Report income for ALL Household Members (Skip this step if participant is categorically eligible as documented in Part I.)
Are you unsure what income to include here? Flip the page and review the charts titled “Sources of Income” for more information.
1
A. Child Income
-
Sometimes children in the household earn or receive income. Please indicate the TOTAL
Child Income/How often?
income received by child household members listed in PART I here.
$________/__________
1
B. Other Household Members
.
List all household members (including yourself) not listed in Part I 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 field blank you are certifying (promising) there is no income to report.
1. Earnings from work before
2. Welfare, child support,
3. Social Security, pensions,
4. All other income /
Name of Other Household Members (First and Last)
deductions / How often
alimony / How Often
retirement / How Often
How Often
1. __________________________________
$ ________/__________
$ ________/_________
$ ________/_________
$ ________/_________
2. __________________________________
$ ________/__________
$ ________/_________
$ ________/_________
$ ________/_________
3. __________________________________
$ ________/__________
$ ________/_________
$ ________/_________
$ ________/_________
4. __________________________________
$ ________/__________
$ ________/_________
$ ________/_________
$ ________/_________
5. __________________________________
$ ________/__________
$ ________/_________
$ ________/_________
$ ________/_________
_____
C.
Total Household Members (Adults and Children) listed in Part I and Part II
Social Security Number.
If income is listed or completed in Part II, the adult completing the form must also list the last four digits of his or her Social Security Number or check the “I don’t
have a Social Security Number” box below. (See Privacy Act Statement on next page).
Failure to complete this section, if income is listed, will result in the denial of free or reduced eligibility.
Last four Digits of Social Security Number XXX-XX___________
I do not have a Social Security Number
PART III: Enrollment
Information:
Children Only
My child is normally in attendance at the facility between the hours of _______ [am/pm] to _____ [am/pm].
() Check here if only before/after school care is provided.
Circle the days your child will normally attend the center:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Circle the meals your child will normally receive while in care:
Breakfast
AM Snack
Lunch
PM Snack
Supper
Evening Snack
PART IV: Signature
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 purposefully give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted. This
signature also acknowledges that the child(ren) or adult listed on the form in Part I are enrolled for care.
If not completed fully and signed, the participant will be placed in the Paid category.
X
Signature:
_______________________________________________________________
Print Name: _____________________________________
Date: _________________________
Address: ____________________________________________
City: ________________________
State: _______
Zip: __________
Phone: _______________
*This application is a revision of USDA’s newly released meal benefit prototype and meets all legal requirements and reflect design best practices identified by USDA through focus testing and other research.
PART V: Participant’s Ethnic and Racial Identities (optional)
Check () one ethnic identity:
Check () one or more racial identities:
Hispanic/ Latino
Not Hispanic/ Latino
Asian
White
Black or African American
Indian or Alaska Native
Hawaiian or other Pacific Islander
Official Use Only Section for Provider: 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 Eligibility: check () if applicable
Eligibility: check () one Free
Reduced
Paid-Denied
Day Care Homes Only: check () one Tier I
Tier II
When more than one person is performing CACFP duties, there must be at least two signatures on this form: one signature from the Determining Official (the official who
determined initial income classification) and one signature from the Confirming Official (the official who verified the form’s accuracy).
Determining Official’s Signature: ____________________________________________
Date: _______________________________
Confirming Official’s Signature: _____________________________________________
Date: _______________________________
Follow Up Official’s Signature: ______________________________________________
Date: _______________________________
05/2018
Bright from the Start: Georgia Department of Early Care and Learning
CACFP Meal Benefit Income Eligibility Statement*
PART I: Child(ren) or Adult enrolled to receive day care
Children in Head Start, foster care and children who meet the
SNAP, TANF, or FDPIR case number, or
definition of migrant, runaway, or homeless are eligible for
Client ID number for children only. All the
free meals. Check () all that apply.
(See definitions in FAQs)
above, or SSI or Medicaid case number for
Adults. Note: Do not use EBT numbers.
Foster
Head Start
Migrant
Runaway
Homeless
Child
Write case number and proceed to Part III.
Name: (Last, First and Middle Initial)
PART II: Report income for ALL Household Members (Skip this step if participant is categorically eligible as documented in Part I.)
Are you unsure what income to include here? Flip the page and review the charts titled “Sources of Income” for more information.
1
A. Child Income
-
Sometimes children in the household earn or receive income. Please indicate the TOTAL
Child Income/How often?
income received by child household members listed in PART I here.
$________/__________
1
B. Other Household Members
.
List all household members (including yourself) not listed in Part I 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 field blank you are certifying (promising) there is no income to report.
1. Earnings from work before
2. Welfare, child support,
3. Social Security, pensions,
4. All other income /
Name of Other Household Members (First and Last)
deductions / How often
alimony / How Often
retirement / How Often
How Often
1. __________________________________
$ ________/__________
$ ________/_________
$ ________/_________
$ ________/_________
2. __________________________________
$ ________/__________
$ ________/_________
$ ________/_________
$ ________/_________
3. __________________________________
$ ________/__________
$ ________/_________
$ ________/_________
$ ________/_________
4. __________________________________
$ ________/__________
$ ________/_________
$ ________/_________
$ ________/_________
5. __________________________________
$ ________/__________
$ ________/_________
$ ________/_________
$ ________/_________
_____
C.
Total Household Members (Adults and Children) listed in Part I and Part II
Social Security Number.
If income is listed or completed in Part II, the adult completing the form must also list the last four digits of his or her Social Security Number or check the “I don’t
have a Social Security Number” box below. (See Privacy Act Statement on next page).
Failure to complete this section, if income is listed, will result in the denial of free or reduced eligibility.
Last four Digits of Social Security Number XXX-XX___________
I do not have a Social Security Number
PART III: Enrollment
Information:
Children Only
My child is normally in attendance at the facility between the hours of _______ [am/pm] to _____ [am/pm].
() Check here if only before/after school care is provided.
Circle the days your child will normally attend the center:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Circle the meals your child will normally receive while in care:
Breakfast
AM Snack
Lunch
PM Snack
Supper
Evening Snack
PART IV: Signature
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 purposefully give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted. This
signature also acknowledges that the child(ren) or adult listed on the form in Part I are enrolled for care.
If not completed fully and signed, the participant will be placed in the Paid category.
X
Signature:
_______________________________________________________________
Print Name: _____________________________________
Date: _________________________
Address: ____________________________________________
City: ________________________
State: _______
Zip: __________
Phone: _______________
*This application is a revision of USDA’s newly released meal benefit prototype and meets all legal requirements and reflect design best practices identified by USDA through focus testing and other research.
PART V: Participant’s Ethnic and Racial Identities (optional)
Check () one ethnic identity:
Check () one or more racial identities:
Hispanic/ Latino
Not Hispanic/ Latino
Asian
White
Black or African American
Indian or Alaska Native
Hawaiian or other Pacific Islander
Official Use Only Section for Provider: 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 Eligibility: check () if applicable
Eligibility: check () one Free
Reduced
Paid-Denied
Day Care Homes Only: check () one Tier I
Tier II
When more than one person is performing CACFP duties, there must be at least two signatures on this form: one signature from the Determining Official (the official who
determined initial income classification) and one signature from the Confirming Official (the official who verified the form’s accuracy).
Determining Official’s Signature: ____________________________________________
Date: _______________________________
Confirming Official’s Signature: _____________________________________________
Date: _______________________________
Follow Up Official’s Signature: ______________________________________________
Date: _______________________________
05/2018
The participant in the day care facility may qualify for free or reduced-price meals if your household
income falls within the limits on the Annual Income Eligibility Guidelines.
Household Size
Yearly Income
1
2
3
Please refer to the Income
4
Eligibility Guidelines that are
5
updated annually and
6
available on DECAL’s
website.
7
8
Each additional person
Add:
Privacy Act Statement: 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 your child for free or reduced-price meals. You must
include the social security 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 Food Stamp, Temporary Assistance for Needy Families (TANF) Program
or Food Distribution Program on Indian Reservations (FDPIR) case number for your child 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 your child is eligible for free or reduced-price meals, and for administration and enforcement of the
Program.
Non-discrimination 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 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 mail: U.S. Department of Agriculture, Office of the Assistant Secretary
for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; fax: (202) 690-7442; or email:
program.intake@usda.gov.
This institution is an equal opportunity provider.
1
Sources of Income Chart
05/2018
INSTRUCTIONS
Households that receive SNAP, TANF, FDPIR, SSI or Medicaid: Complete the following:
Part I: For family day care home and child care center, list participant’s name and a SNAP, TANF, or FDPIR case
number. For adult day care, list participant’s name and a SNAP, TANF, FDPIR, SSI or Medicaid case number. Note:
foster children (children placed in the household by the court system) can be included in this section. A separate
form is no longer needed for foster children. Note:
Children in Foster care, enrolled in Head Start and children who meet
the definition of Homeless, Migrant or Runaway are eligible for free meals. Please refer to the Q&A section for a definition of
each free categorical eligibility.
Part II: Skip this part.
Part III: Child care centers only. Provide the normal days and hours your child is in attendance in the center and indicate
the meals he/she normally receives while in care.
Part IV: Sign the form. A Social Security Number is not necessary.
Part V: Answer this question if you choose to.
All other Households, including WIC households, complete the following:
Part I: For family day care home, child care center or adult day care, list participant’s name.
Part II: To report total household income from last month, complete the following:
A- Child Income: Please indicate the TOTAL income received by Child household members listed in PART I. Please list
any child income and how often it is received in this section.
B – Adult Income: List the first and last name of each Adult person living in your household as an economic unit. You
must indicate yourself and all other adult members living with you. In the case of an adult participant, the adult
participant, and if residing with the adult participant, the spouse and dependent(s) of the adult participant should be listed
here as well. Attach another sheet if necessary.
List Gross Income. Next to each person’s name, list each type of income received last month, and how often it was
received.
B-Column 1: List the gross income each person earned from work. This is not the same as take-home pay. Gross income
is the amount earned before taxes and other deductions. The amount should be listed on your pay stub, or your boss can
tell you. Next to the amount, write how often the person got it (weekly, every other week, twice a month, or monthly).
B-Column 2: List the amount each person got last month from welfare, child support, alimony.
B-Column 3: List Social Security, pensions, and retirement.
B-Column 4: List all other income sources including Worker’s Compensation, unemployment, strike benefits,
Supplemental Security Income (SSI), Veteran’s benefits IVA benefits), disability benefits, regular contributions from
people who do not live in your household. Report net income from self-owned businesses, farming, or rental income.
Next to the amount, write how often the person got it. If you are in the Military Housing Privatization Initiative do not
include this housing allowance.
Social Security Number: If income is listed or completed in Part II, the adult completing the form must also list the last
four digits of his or her Social Security Number or mark the “I don’t have a Social Security Number” box.
If no income: If the person does not receive income from any source, write “0”. If “0” is entered or any income field are
blank, the person is certifying that there is no income to report.
C – Total Household Members. Please list the total number of all household members (children and adults) in this
section.
Part III: Child care centers only. Provide the normal days and hours your child is in attendance in the center and indicate
the meals he/she normally receives while in care.
Part IV: An adult household member must complete this section completely and then sign the form. Please refer back to
Part II to ensure the last four digits of his/her social security number have been recorded or the box has been marked if
he/she does not have one.
Part V: Answer this question if you choose to.
Privacy Act Statement: This explains how we use the information you give us.
05/2018
The Child and Adult Care Food Program
Income Eligibility Statement Form and Supporting Documents
The United States Department of Agriculture (USDA) issued revised Income Eligibility Statements (IES)
and other required forms to all state agencies to disseminate to institutions participating in the Child
and Adult Care Food Program (CACFP). The newly revised IES package includes the following: IES form
and instructions, reduced income guidelines template with privacy and non-discrimination statement,
Sharing Information with Medicaid/SCHIP letter, sample house-hold letters based on program type, and
template letters to use when verifying income and reporting the results of the verification. This newly
revised IES application conforms to USDA’s newly released prototypes and therefore meet all legal
requirements and reflect design best practices identified by USDA through focus testing and other
research.
The revised IES package and supporting documents is available at
http://www.decal.ga.gov/BftS/FormList.aspx?cat=CACFP.
Frequently Asked Questions
Q. What information do I issue to parents?
A. Institutions and facilities should issue the IES form, reduced income guidelines with the privacy and
non-discrimination statement, appropriate household letter, and the Sharing Information with
Medicaid/SCHIP letter to parents/guardians of children/adults participating in the CACFP.
Q. Can centers/day care homes require parents/guardians to complete the IES form as part of the
enrollment package?
A. Centers/day care homes can request that parents/guardians complete the form as part of the
enrollment process, but centers should not require parents/guardians to complete the form nor should
they have policies/practices in place that negatively impacts the prospective/current participant’s
enrollment if the parent declines or fails to complete or submit the form. This action would be in
violation of the Program.
Q. Why is it necessary to issue the Sharing Information with Medicaid/SCHIP letter to parents?
A. Parents/guardians that do not wish to have their information shared with either Medicaid or SCHIP
must complete the form and return to facility. Otherwise and when requested by Bright from the Start
or the United States Department of Agriculture (USDA), parent/guardian information will be shared with
Medicaid/SCHIP.
Q. Is it necessary to have three official’s signatures on the new IES form-especially when the center is
an independent center with only one staff person managing the CACFP?
A. No. Only one signature is required for Independent centers with only one staff person responsible for
managing the CACFP. However, institutions with more than one person managing the CACFP, and
center and administrative sponsors are required to have a minimum of two signatures: determining
official and confirming official.
05/2018
Q. What is the purpose of having a determining and confirming official signature?
A. The confirming official will review the form and ensure accuracy and completeness. IES forms are
considered current and valid until the last day of the month in which the form was dated on year earlier.
The date to be used to make this determination is the date in which the sponsor or institution official
signs the IES form to certify eligibility of the participant.
Q. How long is the IES form considered current and valid?
A. IES forms are considered current and valid until the last day of the month in which the form was
dated one year previously. The date used to make this determination is the date in which the sponsor/
independent center official or parent/guardian signs the IES form. CACFP institutions and SFSP sponsors
must decide which date they will use as the effective date and apply this date to all income eligibility
forms submitted on behalf of all participants. CACFP institutions and SFSP sponsors are required to
complete the Income Eligibility - Effective Date Option Form. In addition, institutions must indicate the
options chosen in Section VIII. Recordkeeping (Item #2) of their Management Plan.
This means that sponsor and independent center officials should not request parent/guardians to
complete IES forms at a specific frequency (e.g. start of each school year, every June, etc.). Request
made by the sponsor or independent center official for IES form completion should be based solely on
the expiration date of the IES forms.
Q. Do I send a report to Bright from the Start listing parent/guardians that want their information
shared with Medicaid/SCHIP?
A. No. When instructed by USDA, Bright from the Start will request and collect data from institutions.
Q. Can this form be used for children in childcare facilities and adults in adult daycare facilities?
A. Yes.
Q. Can siblings be listed on one form?
A. Yes. Siblings from the same household can be listed on one form as long as there is space available.
Q. When do I verify parent/guardian income?
A. At the request of the United States Department of Agriculture (USDA), Bright from the Start, or any of
its agents.
Q. Where can I get copies of the IES form and supporting documents?
A. Access Bright from the Start’s webpage at
http://www.decal.ga.gov/BftS/FormList.aspx?cat=CACFP
Q. Can I still participate in the CACFP if parents do not complete the IES form or do not return the
form to my center?
A. Yes. However, children that do not have IES forms on file must be placed in the “paid” category on
the roster, which will effect monthly reimbursement. Centers that are using the IES form to capture
annual enrollment information will be required to use an alternate enrollment form that captures at a
minimum the name of the child, normal hours and days of care and meals the child usually receives
while in attendance.
05/2018
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