The Child and Adult Care Food Program (CACFP) makes good food a regular part of your child’s day care! Please fill out the CACFP Meal Benefit Income Eligibility form. It helps us find out if your household qualifies for free or reduced-price meals. This lets us know how much money CACFP will give to support your day care home or center.

Instructions

Here are instructions to help you fill out the form. Before you begin, turn the form over to learn why we ask for this information. It tells you how we use the information and what rights you have. It also tells you how to contact USDA if you believe you are treated unfairly.

Please make sure to fill in all of the requested information. Use a pen to mark your answers on one form. When you are finished, please return the form to your center director or contact us.

Step 1:

List all the children from your household in the day care. Use one line for each child’s name. Write one letter in each box. Stop if you run out of space. If there are more children, add their names on a second piece of paper.

Do you have any foster children? If you answer Yes, mark the Foster Child box next to the child’s name. If you are only applying for foster children, finish Step 1 and go to Step 4. If you are applying for both foster and non-foster children, go to Step 2.

Are any children migrant, runaway, homeless, or enrolled in Head Start? If Yes, mark the correct boxes next to the child’s name and go to Step 4.

Step 2:

You qualify for free meals if you live in a household that receives Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), or Food Distribution Program on Indian Reservations (FDPIR).

Do any household members, including you, currently receive SNAP, TANF, or FDPIR? If Yes, write the case number in the box and go to Step 4. You only need to provide one case number. If No, go to Step 3.

Step 3:

Report current income for all household members. Skip this step if you answered Yes in Step 2.

How do you report child income? Turn the form over and use the Source of Income for Children chart to see if your household has income to report. Write the amount in the boxes in part A of the form. Mark how often the amount is earned. Write 0 in the box if there is no income to report.

How do you report income of adult household members? Turn the form over and use the Source of Income for Adults chart to see if your household has income to report.

In part B, list all the adults in your household, including you, even if each of you doesn’t receive income. Include all adults, such as grandparents, other relatives, and friends who live with you and share household income and expenses. Write the amount of income each of you receives, in the boxes next to your names. Mark how often the amount is received. Write 0 in the box if there is no income to report.

Make sure you report the current amount of money you get before taxes. Don’t include SNAP, FDPIR, WIC, student financial aid, or money you receive for a foster child as income.

Count the number of all children and adults in your household. Include all infants, children, students, and adults. Write the total number in the box under the list of adult household members.

Do you or another adult household member have a Social Security number? Write the last four digits in the boxes. If there is no Social Security number, mark the Check if no SSN box.

Points to Remember:

Step 4:

An adult household member must sign this form. The signer promises that all information is true and complete.

Print the name, address, and telephone or email of the adult signer. Sign and write today’s date in the marked boxes.

Optional

We ask about your children’s ethnicity and race to make sure we do our best to serve our community. Providing this information is not required. You won’t be denied benefits based on your race, color, national origin, sex, age, or disability.