Attachment 10 "Income Eligibility Form for the Summer Food Service Program (For Use by Camps and Closed Enrolled Sites)" - Georgia (United States)

What Is Attachment 10?

This is a legal form that was released by the Georgia Department of Early Care and Learning - a government authority operating within Georgia (United States). As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2020;
  • The latest edition provided by the Georgia Department of Early Care and Learning;
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  • Fill out the form in our online filing application.

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Attachment 10
INCOME ELIGIBILITY FORM
FOR THE
SUMMER FOOD SERVICE PROGRAM
(For Use by Camps and Closed Enrolled Sites)
Please complete the following form using the instructions below. Sign the form and return it to:
________________________________________________________________ [name of Sponsor]
If you need help, call _______________________________________________ [phone number of Sponsor]
Follow these instructions if your household gets SNAP TANF or FDPIR:
Part 1: List participant’s name and a SNAP, TANF or FDPIR case number.
Part 2: Skip this part.
Part 3: Skip this part.
Part 4: Sign the form. A Social Security Number is NOT required.
Part 5: Answer this question if you choose to.
If your household includes a FOSTER CHILD, use one application for the whole household and follow these
instructions:
Part 1: Enter the child’s name.
Part 2: Please contact us at [phone number of Sponsor]
Part 3: Complete this part if you are applying for other children in the household and you did not enter a SNAP, TANF or
FDPIR case number in Part 1.
Part 4: Sign the form. If Part 3 was completed, provide the last four digits of the signing adult’s Social Security Number.
Part 5: Answer this question if you choose to.
ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:
Part 1: List each participant’s name.
Part 2: Skip this part.
Part 3: Follow these instructions to report total household income from last month.
Column A
Name: List the first and last name of each person living in your household, related or not (such as
grandparents, other relatives, or friends who live with you). You must include yourself and all children living with
you. Attach another sheet of paper if you need to.
Column B
Gross income last month and how often it was received. Next to each person’s name, list each
type of income received last month, and how often it was received.
In Box 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).
In box 2, list the amount each person got last month from welfare, child support, alimony.
In box 3, list Social Security, pensions, and retirement.
In box 4, list ALL OTHER INCOME SOURCES including Worker’s Compensation, unemployment, strike benefits,
Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), disability benefits, regular contributions
from people who do not live in your household. Report net income for self-owned business, farm, 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.
Column C
Check if no income: If the person does not have any income, check the box.
Part 4: An adult household member must sign the form and include the last four digits of his or her Social Security
Number, or mark the box if he or she doesn’t have one.
Part 5: Answer this question if you choose to.
Income Eligibility Form for SFSP, Att. 10 (Revised 11/2020)
Page 1 of 3
Attachment 10
INCOME ELIGIBILITY FORM
FOR THE
SUMMER FOOD SERVICE PROGRAM
(For Use by Camps and Closed Enrolled Sites)
Please complete the following form using the instructions below. Sign the form and return it to:
________________________________________________________________ [name of Sponsor]
If you need help, call _______________________________________________ [phone number of Sponsor]
Follow these instructions if your household gets SNAP TANF or FDPIR:
Part 1: List participant’s name and a SNAP, TANF or FDPIR case number.
Part 2: Skip this part.
Part 3: Skip this part.
Part 4: Sign the form. A Social Security Number is NOT required.
Part 5: Answer this question if you choose to.
If your household includes a FOSTER CHILD, use one application for the whole household and follow these
instructions:
Part 1: Enter the child’s name.
Part 2: Please contact us at [phone number of Sponsor]
Part 3: Complete this part if you are applying for other children in the household and you did not enter a SNAP, TANF or
FDPIR case number in Part 1.
Part 4: Sign the form. If Part 3 was completed, provide the last four digits of the signing adult’s Social Security Number.
Part 5: Answer this question if you choose to.
ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:
Part 1: List each participant’s name.
Part 2: Skip this part.
Part 3: Follow these instructions to report total household income from last month.
Column A
Name: List the first and last name of each person living in your household, related or not (such as
grandparents, other relatives, or friends who live with you). You must include yourself and all children living with
you. Attach another sheet of paper if you need to.
Column B
Gross income last month and how often it was received. Next to each person’s name, list each
type of income received last month, and how often it was received.
In Box 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).
In box 2, list the amount each person got last month from welfare, child support, alimony.
In box 3, list Social Security, pensions, and retirement.
In box 4, list ALL OTHER INCOME SOURCES including Worker’s Compensation, unemployment, strike benefits,
Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), disability benefits, regular contributions
from people who do not live in your household. Report net income for self-owned business, farm, 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.
Column C
Check if no income: If the person does not have any income, check the box.
Part 4: An adult household member must sign the form and include the last four digits of his or her Social Security
Number, or mark the box if he or she doesn’t have one.
Part 5: Answer this question if you choose to.
Income Eligibility Form for SFSP, Att. 10 (Revised 11/2020)
Page 1 of 3
Part 1. Children enrolled in Camp or Closed Enrolled Sites.
Names
SNAP, TANF or FDPIR case # (if any). Skip to Part 4 if
(First, Middle Initial, Last)
you listed a case #.
Part 2. Foster Child
Foster children are eligible for free and reduced-price meals regardless of household income. If a foster child lives with you,
please contact ______________________________________ [name of Sponsor] at _______________________
[phone number]. Complete Part 3 if you are applying for other children in your household and you did not enter a SNAP,
TANF or FDPIR case number in Part 1.
Part 3. Total Household Gross Income—You must tell us how much and how often
B. Gross income and how often it was received
C.
Example: $100/monthly $100/twice a month $100/every other week $100/weekly
A. Name
Check
1. Earnings from work
2. Welfare, child
3. Social Security,
(List everyone in household,
if no
before deductions
support, alimony
pensions, retirement, 4. All Other Income
including children)
income
(Example)
Jane Smith
$200/weekly_____
$150/weekly_____ $100/monthly_____
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
$______/
Part 4. Signature and Social Security Number (Adult must sign)
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 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 this information is being
given for the receipt of Federal funds. I understand that SFSP 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: X
Print name:
Date:
Address:
Phone Number:
☐ I do not have a Social Security Number
Last four digits of 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
Do not 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
Per: ☐ Week, ☐ Every 2 Weeks,
☐ Twice A Month, ☐ Month, ☐ Year
Total Income:
Household size:
Date Withdrawn:
Eligibility:
Categorical Eligibility: ___
Free___ Reduced___ Paid___
Date Reason:
Date:
Determining Official’s Signature:
Confirming Official’s Signature:
Date:
Follow-up Official’s Signature:
Date:
Income Eligibility Form for SFSP, Att. 10 (Revised 11/2020)
Page 2 of 3
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 number 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 SNAP, 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
(English) or
USDA Program Discrimination Complaint Form
(Spanish) This form (AD-3027) is found online at:
https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complaint
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.
Income Eligibility Form for SFSP, Att. 10 (Revised 11/2020)
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