Cacfp Form Doh 3688 – Fill Out and Use This PDF

INCOME ELIGIBILITY APPLICATION for Child Day Care Centers

See INSTRUCTIONS on reverse.

DAY CARE CENTER NAME:

Print the name of the child(ren) enrolled in Day Care:

1.

2.

3.

DIRECTIONS:

Complete SECTION A if your household:

Complete SECTION B if Section A does not apply:

1. Receives Temporary Assistance to Needy Families (TANF)

Sign, date and indicate the Social Security number of the adult

2. Receives Food Stamps

signing the certification and return the completed form to the day

3. Participates in the Food Distribution Program on Indian

care center.

Reservations (FDPIR)

4. Currently has a foster child enrolled in day care

SECTION A

SECTION B

TANF Number

List all household members below. Include yourself and all

adults and children NOT listed above, even if they do not

Food Stamp Case Number

receive income. Then list all income received last month in

your household in the column to the right. Gross income

FDPIR Number

includes: earnings from work, pensions, retirement, Social

Security, welfare payments, child support and any other

Foster Child's Name

sources of income.

Foster Child's Personal Monthly Income

$

Name of Household Members

Monthly Gross Income

1.

$

An adult household member must sign the application

before it can be approved. After reading the following

2.

$

statement and the statement on the back, sign below.

3.

$

I certify that the above information is true and correct and that

all income is reported. I understand this information is being

4.

$

given for the receipt of Federal funds, that officials may verify

5.

$

the information on the application; and that deliberate

misrepresentation of the information may subject me to

6.

$

prosecution under applicable State and Federal laws.

An adult household member must sign the application

Signature:

before it can be approved. After reading the following

Date:

statement and the statement on the back, sign below.

I certify that the above information is true and correct and that

FOR SPONSOR USE ONLY

all income is reported. I understand this information is being

given for the receipt of Federal funds, that officials may verify

Sponsor Agreement Number ____________

the information on the application; and that deliberate

misrepresentation of the information may subject me to

Total Household Members ____________

prosecution under applicable State and Federal laws.

Total Income $____________

Free _______

Reduced _______

Paid _______

Signature:

Signature of

Print Name:

Determining Official ______________________________

Date Determined _____ / _____ / _____

SS#

Date:

DOH-3688 (7/08)

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Section 9

Unless you list the child’s food stamp, FDPIR or TANF case number or are applying for a foster child, Section 9 of the National School Lunch Act requires that you include the social security number of the household member signing the application or indicate that the household member signing the application does not have a social security number. You do not have to list a social security number, but if a social security number is not listed or an indication is not made that the adult household member signing the application does not have a social security number, we cannot approve the application. The social security number may be used to identify the household member in verifying the correctness of the information stated on the application. This may include program reviews, audits and investigations and may include contacting employers to determine income, contacting a food stamp, FDPIR or TANF office to determine current certification for food stamps, FDPIR or TANF benefits, contacting the State employment security office to determine the amount of benefits received and checking the documentation produced by the household member to prove the amount of income received. These efforts may result in a loss or reduction of benefits, administrative claims or legal actions if incorrect information is reported.

Definition of Income

Income means income before deductions for income taxes, social security taxes, insurance premiums, charitable contributions, and bonds, etc. It includes the following: (1) monetary compensation for services, including wages, salary, commissions or fees; (2) net income from non-farm self-employment; (3) net income from farm self-employment; (4) social security payments; (5) dividends or interest on savings or bonds, income from estates or trusts or net rental income; (6) public assistance or welfare payments; (7) unemployment compensation; (8) government civilian employee or military retirement, or pensions or veteran’s payments; (9) private pensions or annuities; (10) alimony or child support payments; (11) regular contributions from persons not living in the household;

(12)net royalties; (13) military benefits received in cash, such as housing allowance; and (14) any other cash income.

Definition of Household

Household means family as defined in Section 226.2. Family means a group of related or non-related individuals who are not residents of an institution or boarding house, but who are living as one economic unit.

INSTRUCTIONS FOR COMPLETING DOH-3688

Instructions for Parents or Guardians:

Write in the name of the day care center in the space provided.

Print the name of each child in your household who attends this day care center.

Section A: If your household receives Temporary Assistance for Needy Families (TANF) or Food Stamps or participates in the Food Distribution Program on Indian Reservations (FDPIR), complete Section A only. Write down the TANF, FS or FDPIR number (do not use your ACD or DSS child care subsidy number) and sign and date the form and return it to the day care center.

Foster children: If your household includes a foster child who is in day care, complete Section A only. Write in the foster child’s name and any income that the child receives from social services for his or her personal use. Write in 0 if the foster child does not receive any income. A separate application must be completed for each foster child. The foster parent or an official who represents the child must sign and date the form and then return it to the day care center.

Section B: Write in the names of all the people living in your household, even if they do not have any income. Include yourself and all other adults and children in the household, including unrelated people. Do not include the children in day care, who are listed at the top of the form.

Enter the amount of income each person received last month, before taxes or anything else was taken out. Refer to the Definition of Income and the Definition of Household above. If any amount last month was more or less than the usual, write in that person’s usual income. The signature and social security number of the adult signing the certification is required. If you do not have a social security number, write none.

Instructions for Centers and Sponsors

The For Sponsor Use Only section is to be completed, signed and dated by day care center or sponsor staff.

The sponsor/center representative must review the income eligibility application and ensure that it is completed as indicated in the instructions above. Then indicate the following:

The sponsor agreement number.

Total household members – This item does not have to be completed if the parent completed Section A. Add those indicated in Section B (if completed) to the children enrolled in day care.

Total Income – This item does not need to be completed if the parent completed Section A. Indicate the total monthly income as calculated from Section B. If the parent chooses not to disclose income, the application must be categorized as paid.

Free, Reduced or Paid – Compare the total household income and the total number of household members with the current year’s Income Eligibility Guidelines (CACFP-3687) to determine if the household should be categorized as Free, Reduced or Paid. Use the appropriate column on the CACFP-3687 to categorize their income. For example, if the parent indicated biweekly income, multiply this amount by 26 to determine yearly income.

Incomplete applications (missing signatures, income information, social security numbers, TANF FDPIR or Food Stamp numbers) are categorized in the paid category.

The income eligibility application is valid for one calendar year only.

DOH-3688 (7/08)

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