DSS Form 1645 "Application for Free and Reduced-Price Meals in Adult Care Food Programs" - South Carolina

What Is DSS Form 1645?

This is a legal form that was released by the South Carolina Department of Social Services - a government authority operating within South Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2017;
  • The latest edition provided by the South Carolina Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of DSS Form 1645 by clicking the link below or browse more documents and templates provided by the South Carolina Department of Social Services.

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Download DSS Form 1645 "Application for Free and Reduced-Price Meals in Adult Care Food Programs" - South Carolina

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South Carolina Department of Social Services
APPLICATION FOR FREE AND REDUCED-PRICE MEALS
IN ADULT CARE FOOD PROGRAMS
Part 1. Name of Enrolled Adult:
Last
First
M.I.
Age
Part 2. All Household Members (Including Enrolled Adult)
Name of Household Members
(See instructions for definition of household)
Check If No Income
(First, Middle Initial, Last)
n
n
n
n
n
n
n
n
n
n
Part 3. Benefits: If any member of your household received SNAP (formerly Food Stamps) or Food Distribution
Program on Indian Reservation (FDPIR), or the adult participant receives Social Security Income (SSI) or Medicaid,
provide the name and case number for the person who receives benefits. If no one receives these benefits, skip to
part 4.
Name:
Case No.:
Part 4. Total Household Gross Income – You must tell us how much and how often.
B. Gross income and how often it was received
A. Name
1. Earnings from work
2. Welfare, child
3. Pensions,
4. All Other Income
(List only household members
before deductions
support, alimony
retirement, Social
with income)
Security, SSI, VA
benefits
(Example)
$
200 / weekly
$150 / twice a month
$
100 / monthly
$
/
Jane Smith
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
Part 5. Signature and Last Four Digits of Social Security Number (Adult must sign)
An adult household member must sign this form. If Part 4 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 Privacy Act Statement page 3.)
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:
n
n
Last Four Digits of Social Security Number: xxx - xx -
I do not have a Social Security Number
DSS Form 1645 (JUN 17) Edition of JUL 16 is obsolete.
Reset
South Carolina Department of Social Services
APPLICATION FOR FREE AND REDUCED-PRICE MEALS
IN ADULT CARE FOOD PROGRAMS
Part 1. Name of Enrolled Adult:
Last
First
M.I.
Age
Part 2. All Household Members (Including Enrolled Adult)
Name of Household Members
(See instructions for definition of household)
Check If No Income
(First, Middle Initial, Last)
n
n
n
n
n
n
n
n
n
n
Part 3. Benefits: If any member of your household received SNAP (formerly Food Stamps) or Food Distribution
Program on Indian Reservation (FDPIR), or the adult participant receives Social Security Income (SSI) or Medicaid,
provide the name and case number for the person who receives benefits. If no one receives these benefits, skip to
part 4.
Name:
Case No.:
Part 4. Total Household Gross Income – You must tell us how much and how often.
B. Gross income and how often it was received
A. Name
1. Earnings from work
2. Welfare, child
3. Pensions,
4. All Other Income
(List only household members
before deductions
support, alimony
retirement, Social
with income)
Security, SSI, VA
benefits
(Example)
$
200 / weekly
$150 / twice a month
$
100 / monthly
$
/
Jane Smith
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
Part 5. Signature and Last Four Digits of Social Security Number (Adult must sign)
An adult household member must sign this form. If Part 4 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 Privacy Act Statement page 3.)
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:
n
n
Last Four Digits of Social Security Number: xxx - xx -
I do not have a Social Security Number
DSS Form 1645 (JUN 17) Edition of JUL 16 is obsolete.
INSTRUCTIONS FOR DSS FORM 1645
Follow these instructions, if your household gets SNAP, FDPIR, SSI or Medicaid:
Part 1: List all enrolled adult(s).
Part 2: List all household members. This includes the adult participant, and if residing with the adult participant, the
spouse and dependent(s) of the adult participant. Functionally impaired adults living with their parents are
considered a “family” or “household” separate from their parents for the purpose of determining household size
and income.
Part 3: List the case number for any household member receiving Supplemental Nutrition Assistance Program (SNAP)
(formerly Food Stamp), and/or Food Distribution Program on Indian Reservations (FDPIR). List the case number
for the participant if he/she receives Social Security Income (SSI) or Medicaid benefits.
Part 4: Skip this part.
Part 5: Sign and date the form. The last four digits of a Social Security Number are not necessary.
ALL OTHER HOUSEHOLDS, follow these instructions:
Part 1: List all enrolled adult(s).
Part 2: List all household members. This includes the adult participant, and if residing with the adult participant, the
spouse and dependent(s) of the adult participant. Functionally impaired adults living with their parents are
considered a “family” or “household” separate from their parents for the purpose of determining household size
and income.
Part 3: Skip this part.
Part 4: Follow these instructions to report total household income from this month or last month.
Column A – Name: List only the first and last name of each household member with income. Household members
include the adult participant, and if residing with the adult participant, the spouse and dependent(s) of the adult
participants. Attach another sheet of paper if you need to.
Column B – Gross Income and How Often it was Received: For each household member who is a spouse, or
dependent of the participant, list each type of income received for the month. You must tell us how often the money
is received – weekly, every other week, twice a month, or monthly.
Box 1: List the gross income, not the take-home pay. Gross income is the amount earned before taxes and
other deductions. You should be able to find it on your stub or your boss can tell you.
Box 2: List the amount each person got from the month from welfare, child support, alimony.
Box 3: List retirement, Social Security, Supplemental Security Income (SSI), Veteran’s (VA) benefits, disability
benefits.
Box 4: List ALL OTHER INCOME SOURCES including Worker’s Compensation, unemployment, strike benefits,
regular contributions from people who do not live in your household, and any other income. For ONLY
the self-employed, report income after expenses in Box 1. Box 4 is for your business, farm or rental
property. Do not include income from SNAP, FDPIR, WIC or Federal education benefits. If you are in the
Military Housing Privatization Initiative or get combat pay, do not include this housing allowance as
income.
Part 5: Adult household member must sign and date the form and list the last four digits of the Social Security Number
or mark the box if s/he doesn’t have one.
DSS Form 1645 (JUN 17)
PAGE 2
INSTRUCTIONS FOR DSS FORM 1645, continued
Part 6. Participant’s ethnic and racial identities (optional)
Mark one ethnic identity:
Mark one or more racial identities:
n
n
n
n
n
n
Hispanic or Latino
Asian
American Indian or Alaska Native
n
n
n
n
n
n
Not Hispanic or Latino
White
Native Hawaiian or Other Pacific Islander
n
n
Black or African American
The participant in the adult day care facility
Household Size
Yearly
may qualify for free or reduced price meals
1
$ 22,311
if your household income falls within the
limits on this chart.
2
30,044
3
37,777
4
45,510
5
53,243
6
60,976
7
68,709
8
76,442
Each additional person
+ 7,733
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 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), Family Independence (FI) Program or Food Distribution Program on Indian Reservations (FDPIR) case number
for the participant or other (FDPIR) identifier, Supplemental Security Income (SSI), Medicaid case number, 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 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: (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.
For Sponsoring Organization or Adult Care Facility Use ONLY.
Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12
n
n
n
n
n
n
n
n
n
n
Total Income:
per:
Week
Every 2 Weeks
Twice A Month
Month
Year
Household Size:
n
n
n
n
n
n
Categorical Eligibility:
Date Withdrawn:
Eligibility:
Free
Reduced
Paid
Reason:
Determining Official’s Signature:
Date:
Confirming Official’s Signature:
Date:
DSS Form 1645 (JUN 17)
PAGE 3
INSTRUCTIONS FOR DSS FORM 1645, continued
ALL OTHER HOUSEHOLDS, follow these instructions:
Part 6: Answer this question if you choose.
Privacy Act Statement: This explains how we will use the information you give us.
Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly.
For Sponsoring Organization or Adult Care Use ONLY: To be complete by CACFP Institutions only.
DSS Form 1645 (JUN 17)
PAGE 4
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