Fillable HOUSEHOLD ELIGIBILITY APPLICATION FOR CHILD CARE CENTERS CHILD (Illinois State Board of Education)

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HOUSEHOLD ELIGIBILITY APPLICATION FOR CHILD CARE CENTERS CHILD (Illinois State Board of Education)

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4. Homeless, Migrant, or Runaway
Homeless Migrant Runaway Head Start
______________________________________________________________________ __________________
Signature of Homeless Liason, Migrant Coordinator, or Head Start Director Date
5. Total Household Gross Income (before deductions) You must tell us how much and how often.
NAMES
(LIST ALL HOUSEHOLD MEMBERS
WITH INCOME)
GROSS INCOME AND HOW OFTEN IT WAS RECEIVED (Example: $100/month; $100 /twice a month; $100/every other week; $100/week)
Earnings From Work
(Before Deductions)
Welfare, Child
Support, Alimony
Pensions, Retirement,
Social Security
Worker’s Comp., Unemployment,
SSI, etc. (All other income)
Amount How often? Amount How often? Amount How often? Amount How often?
i.
$ $ $ $
ii.
$ $ $ $
iii.
$ $ $ $
iv.
$ $ $ $
v.
$ $ $ $
6. Signature and Social Security Number (Adult must sign)
An adult household member must sign the application. If Section 5 is completed or if zero income
is listed, 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.
__ __ __ - __ __ - __ __ __ __
Social Security Number
I do not have a Social
Security Number.
I certify all information on this application is true and all income is reported. I understand the center will get federal funds based on the information I give. I understand the institution, Illinois
State Board of Education, or Ofce of Inspector General, may verify this information on the application. Deliberate misrepresentation of the information may subject me to prosecution under
applicable state and federal laws.
_________________________ _________________________________________ _________________________________________________________
Date Printed Name of Adult Household Member Signature of Adult Household Member
7. Contact Information (Optional)
________________________________________ ______________________________________ ________________________________________________________________
Work Telephone Number (Include Area Code) Home Telephone Number (Include Area Code) Home Address (Number, Street, City, State, ZIP Code)
8. Children's Racial and Ethnic Identities (Optional)
Mark one ethnic identity:
Hispanic/Latino
Not Hispanic/Latino
Mark one or more racial identities:
Asian Black or African American Native Hawaiian or Other Pacic Islander
White American Indian or Alaska Native
CHILD CARE REPRESENTATIVE USE ONLY
Eligibility Determination - Complete Sections A and B Below
SECTION A
Annual Income Conversion Weekly X 52 Every 2 Weeks X 26 Twice a Month X 24 Once a Month X 12
TOTAL
INCOME $ ____________________ Per: Week Every 2 Weeks Twice a Month Month Year NUMBER IN HOUSEHOLD: ______
Free based on:
foster child migrant
SNAP or TANF runaway
homeless household’s income
Head Start
Reduced based on:
household’s income
Denied — Reason:
income too high
incomplete application
Non-qualifying SNAP/TANF
SECTION B
Signature of Determining Ofcial: __________________________________________________________ Date: _____________________________________
HOUSEHOLD ELIGIBILITY APPLICATION FOR CHILD CARE CENTERS
CHILD AND ADULT CARE FOOD PROGRAM
1. All Household Members 2. 3.
x x x x x
ISBE 69-88 (5/21) Effective July 1, 20
21
Convert income only if different
frequencies of pay are reported.
NAMES OF ALL HOUSEHOLD MEMBERS
First, Middle Initial, Last
Ages of Children
at Center
FOSTER CHILD
Foster children are a legal responsibility of
DCFS or court. If all are foster children,
skip to Section 6
SNAP OR TANF CASE NUMBER Skip to Part 6 if you list a SNAP or TANF
case number. At least one SNAP/TANF must be provided below.
9. Optional – Sharing Information With All Kids Insurance Program
May we share your information on this application with the All Kids Insurance Program, the complete health insurance program for every child in Illinois? If yes, do not sign below.
No, I do not want my information from this application shared with the All Kids Insurance Program.
Date: _______________________________ Sign here: ___________________________________________________________
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INSTRUCTIONS FOR APPLYING - COMPLETE ONE APPLICATION PER HOUSEHOLD
Follow These Instructions and Return the Completed form to your Center. Once approved for meal benets, a child’s Household Eligibility Application is
effective for 12 months.
FOSTER CHILD(REN)
A foster child remains the legal responsibility of the state through a foster care agency or the court. If you submit documentation from the state or local
agency that the child is in foster care, that documentation replaces completing a Household Eligibility Application.
1) If all children in your household (who attend this center) are foster children that are the legal responsibility of a foster care agency or court,
provide the following:
• Part 1 — List the name(s) and age(s) of your foster child(ren) attending this center.
• Part 2 — Check the box(es) indicating a foster child(ren).
• Part 3 — 5 Skip
• Part 6 — Provide a signature of an adult household member and date the application.
• Parts 7-9 — (OPTIONAL)
2) If you have some foster children that are the legal responsibility of a foster care agency or court along with other children attending this center,
please provide the following:
• Part 1 — List ALL household members, including the foster child(ren), and the age(s) of the child(ren) attending the center.
• Part 2 — Check the box(es) identifying the foster child(ren).
• Part 3 — Record a valid SNAP/TANF case number if applicable
• Part 4 — Skip
• Complete Parts 5 and 6 if applicable. See the instructions for INCOME–HOUSEHOLDS REPORTING section.
• Parts 7-9 — (OPTIONAL)
SNAP OR TANF BENEFITS - HOUSEHOLDS RECEIVING
If any member (child or adult) of your household receives SNAP or TANF benets, provide the following:
• Part 1 — List ALL people in your household (including grandparents, other relatives, or friends who live with you) and the age(s) of the child(ren)
attending the center.
• Part 2 — Skip
• Part 3 — Record a valid SNAP or TANF case number for any member (child or adult) of this household. You will nd your SNAP or TANF case
number on your letter of eligibility for benets.
• Part 4 — 5 Skip
• Part 6 — Provide a signature of an adult household member and date the application.
• Parts 7-9 — (OPTIONAL)
HOMELESS, MIGRANT, RUNAWAY, OR HEAD START
If no one in your household receives SNAP or TANF benets and if any child is homeless, a migrant, a runaway, or head start, follow these instructions.
• Part 1 — List ALL household members, and the age(s) of the child(ren) attending the center.
• Part 2 — 3 Skip
• Part 4 — If any child you are applying for is homeless, migrant, or a runaway, check the appropriate box and call your local school.
• Part 5 — Complete only if a child in your household isn’t eligible under Part 4. See instructions for INCOME – HOUSEHOLDS
REPORTING section below and complete Parts 5 and 6.
• Part 6 — Provide a signature of an adult household member and date the application.
• Parts 7-9 — (OPTIONAL)
INCOME - HOUSEHOLDS REPORTING
If no one in your household receives SNAP or TANF benets, please report all household income. The Household Eligibility Application must include the
following information:
• Part 1 — List the names of ALL household members and the age(s) of the child(ren) attending the child care center.
• Part 2 — 4 Skip
• Part 5 — List total gross income (before deductions), not take-home pay; and the frequency, how often the money is received, for
each household member for last month. If the income last month was not the usual amount you normally receive, you may provide
a projected amount that better represents your gross income.
o For ONLY the self-employed, list income after expenses. This is for your business, farm, or rental property.
o If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income.
o If you have no income, list zero in the earnings from work column.
• Part 6 — Provide a signature of an adult household member and date the application. Also, provide the last four digits of the Social Security
Number for the adult signing the application. If you refuse to provide the last four digits of the social security number, the application cannot
be approved. If the adult does not have a Social Security Number, mark the box, I do not have a Social Security Number.
• Parts 7-9 — (OPTIONAL)
ISBE 69-88 (5/21) Effective July 1, 2021
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, ofces, 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 benets. 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 le a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027)
found online at http://www.ascr.usda.gov/complaint_ling_cust.html, and at any USDA ofce, 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
Ofce 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.
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 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 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 Reservations (FDPIR) case number or other FDPIR identier for your child 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 Child and Adult Care Food Program. We MAY share your eligibility information with education, health,
and nutrition programs to help them evaluate, fund, or determine benets for their programs, auditors for program reviews, and law enforcement ofcials to help them look
into violations of program rules.
PRIVACY AND DISCRIMINATION STATEMENT
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HOUSEHOLD ELIGIBILITY APPLICATION FOR CHILD CARE CENTERS CHILD (Illinois State Board of Education)

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Completed 28 July 2021

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