CACFP Meal Benefit Income Eligibility (Child Care)
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Complete one application per household. Please use a pen (not a pencil).
List ALL children in day care (if more spaces are required for additional names, attach another sheet of paper)
Child’s First Name MI Child’s Last Name
Foster Child
Migrant Runaway Homeless Head Start
Definition of Household
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.
Check all that apply
Do any household members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?
IF NO > Go to STEP 3
IF YES > Write case number here and proceed 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)
VA Benefits
Weekly Bi-Weekly Monthly 2x Month
Child Income
Weekly Bi-Weekly Monthly Bi-Monthly
Weekly Bi-Weekly 2x MonthMonthly
Are you unsure what
income to include here?
Flip the page and review
the charts titled “Sources
of Income” for more
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 All Adult
Household Members
Contact information and adult signature.
How often?
A. 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)
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.
How often?
How often?
Social Security/SSI/
How often?
Name of Adult Household Members (First and last)
Earnings from Work
Weekly Bi-Weekly Monthly 2x Month
$ $
$ $ $
$ $ $
$ $ $
$ $ $
Last Four Digits of Social Security Number (SSN) of
Check if no SSN
Total Household Members (Children and Adults)
Primary Wage Earner or other Adult Household Member
“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 CACFP ocials
may verify (check) the information. I am aware that if I purposely give false information, the participant/center may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.
Print Name of Adult Signing the Form Signature of Adult
Today’s Date
Address City State Zip
click to sign
click to edit
Source of Income for Children
Sources of Child Income Examples
Earnings from work
A child has a regular full or part-time job where they earn
a salary or wages
Social Security
- Disability Payments
- Survivors Benefits
A child is blind or disabled and receives Social Security benefits
A par
ent is disabled, retired, or deceased, and their child receives
Social Security benefits
Income from person outside of household
A friend or extended family member reguarly gives
a child spending money
Income from any other source
A child receives regular income from a private pension fund,
annuity, or trust
Source of Income for Adults
Earnings from Work
Public Assistance/Alimony/
Child Support
All other sources of income
Salary, wages, cash bonuses
Net income from self-employment
(farm or business)
If you are in the U.S. Military:
Basic pay and cash bonuses (do NOT
include combat pay, FSSA, or privatized
housing allowances)
Allowances for o-base housing, food,
and clothing
Unemployment benefits
Workers compensation
Supplemental Security Income (SSI)
Cash assistance from State or local
Alimony payments
Child support payments
Veterans benefits
Strike benefits
Social Security (including railroad
retirement and black lung benefits)
Private Pensions or disability benefits
Income from trusts or estates
Investment income
Earned interest
Rental income
Regular cash payments from
outside household
Children’s Ethnic and Racial Identities (Optional)
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 aect your children’s eligibility for receiving meals during care.
Ethnicity (check one):
Hispanic or Latino Not Hispanic or Latino
American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Race (check one or more):
The Richard B. Russell National School Lunch Act requires the information on this
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, oces, and
application. You do not have to give the information, but if you do not, the funds your child
employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex,
care center/provider receives may be impacted. You must include the last four digits of
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
the social security number of the adult household member who signs the application. 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.
last four digits of the social security number is not required when you apply on behalf of
a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary
Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.
Reservations (FDPIR) case number or other FDPIR identifier for your child or when you
gov/complaint_filing_cust.html, and at any USDA oce, or write a letter addressed to USDA and provide in the letter all of the information requested in the
indicate that the adult household member signing the application does not have a social
form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
security number. We will use your information to determine the meal reimbursement for
your child care center/provider. We MAY share your eligibility information with education,
MAIL*: U.S. Department of Agriculture
FAX: (202) 690-7442; or *Only use this address if
health, and nutrition programs to help them evaluate, fund, or determine benefits for their
Oce of the Assistant Secretary for Civil Rights
EMAIL: you are filing a complaint
programs, auditors for program reviews, and law enforcement ocials to help them look
of discrimination.
1400 Independence Avenue, SW
This institution is an equal opportunity provider.
into violations of program rules.
Washington, D.C. 20250-9410
For ocial use only
Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly x 12
How often?
Total Income
Weekly Bi-Weekly 2x MonthMonthly
Household size
Categorial Eligibility
Free Reduced Denied
Determining Ocial’s Signature Date Confirming Ocial’s Signature Date Follow-up Ocial’s Signature Date