____________________________
Head Start Eligibility Verification Form
1. Child’s name: ___________________________________________________
2. Child’s date of birth: ______________________________________________
3. Is this child eligible to participate in the program? Yes No
4. Type of eligibility interview conducted: In-person Telephone
5. Indicate the applicable eligibility criterion for this child:
Homeless Other (up to 10% may fall into this
category, up to 49% for AI/AN
Foster care
programs)*
Public assistance (TANF & SSI)
Income between 100-130% FPL (up
Income at or below 100% FPL
to 35% may fall into this category)**
*45 CFR 1302.12(c)(2) specifies that a program may enroll a child who would benefit from services but
does not meet other eligibility requirements provided that these participants only make up to 10 percent of
a program’s enrollment or 49 percent in the case of AI/AN programs as described in 45 CFR 1302.12(e).
**45 CFR 1302.12(d) specifies that a program may enroll an additional 35 percent of participants whose
families do not meet any other eligibility criterion and whose incomes are below 130 percent of the
poverty line.
6. What documentation was used to determine eligibility and is included as part of the
eligibility determination record?
Income Tax Form 1040
W-2
TANF documentation
SSI documentation
Pay stub or pay envelopes
Unemployment documentation
Written statement from employers
Foster care reimbursement
Other, please describe:
7. Staff signature: _______________________
8. Staff name: __________________________
Date: _____________________
Title: ______________________
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this collection of information is estimated to average six minutes per response, including the time for reviewing instructions,
gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and
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