Form Hs 1949 – Fill Out and Use This PDF

PART 1A – NAME OF CHILD CARE CENTER (Enter the name of the child care center):

PART 1B – PARTICIPANT(S) SERVED BY CENTER (Enter the information below for all children from your household that are enrolled for care at the child care center):

PART 2A – HOUSEHOLDS WHICH ARE CURRENTLY RECEIVING BENEFITS THROUGH THE SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP), OR FAMILIES FIRST (FF) CASH ASSISTANCE OR FAMILIES FIRST (FF) CHILD CARE ASSISTANCE (If your household is now receiving benefits under one or more of these programs, complete this part, and sign the statement in Part 4 – Do not complete Part 2B.): ACCENT Case No. for SNAP or FF Cash Assistance: ___________________ OR FF Child

Care Assistance Case No.: _____________________

PART 2B – ALL OTHER HOUSEHOLD MEMBERS (If no information is entered in Part 2A above, complete this part for all household members not identified in Part 1B above and sign the statement in Part 4. Attach additional sheets as necessary)

Total Number of Household Members: ___ Total Yearly Income for Household from All Sources: $ ________________ Yearly income is calculated as follows:

Multiply Weekly income by 52, Bi-weekly income (received every two weeks) by 26, Semi-monthly income (received twice a month) by 24, and Monthly income by 12. Do not round up any numbers.

PART 3 – Medicaid and State Children’s Health Insurance Programs – Please check if you do not want the information in this application to be shared with the Medicaid and State Children’s Health Insurance Programs: ___ DO NOT WANT APPLICATION INFORMATION TO BE SHARED WITH THE MEDICAID AND STATE CHILDREN’S HEALTH INSURANCE PROGRAMS.

PART 4 – SIGNATURE (An adult household member must sign the application.) PENALTIES FOR MISREPRESENTATION: I certify that all of the above information is true and correct. I understand that this information is being given for the receipt of Federal Funds; that institution officials may verify the information on the statement; and that the deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws.

PART 5 – ETHNIC/RACIAL IDENTITY (You are not required to answer this question.): For Ethnicity, please check one of

the following: ___ Hispanic or Latino ___ Not Hispanic or Latino. For Race, please check one or more of the following: ___

American Indian or Alaskan Native ___ Asian ___ Black or African American ___ Native Hawaiian or Other Pacific Islander

___ White. Please see the definitions of Ethnicity and Race on the back of this application.

FOR INSTITUTION USE ONLY: To identify the eligibility classification of the enrolled children identified above, please circle:

Free, Reduced-Price or Paid. To identify the basis for classification, please circle: Categorically Eligible or Income Eligible

Determining Official Signature: ____________________________________________ Date: _______________

INCOME ELIGIBILITY APPLICATION INSTRUCTIONS

PART 1A – NAME OF CHILD CARE CENTER: Enter the name of the child care center.

PART 1B – PARTICIPANT(S) SERVED BY CENTER: Print the name and age of the children from your household that are enrolled for care at the child care center. Also, enter a “Check” for any child(ren) who are foster children.

responsibility of a state children services agency or court, and is categorically eligible for free meals.

PART 2A – HOUSEHOLDS RECEIVING SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM BENEFITS, FAMILIES FIRST CASH ASSISTANCE OR FAMILIES FIRST CHILD CARE ASSISTANCE: COMPLETE THIS PART AND PART 4.

(1)Enter your household’s current case number for Supplemental Nutrition Assistance Program , Families First Cash Assistance or Families First Child Care Assistance. Do not complete Part 2B.

(2)An adult household member must sign the statement in Part 3.

PART 2B - ALL OTHER HOUSEHOLD MEMBERS: COMPLETE THIS PART AND PART 4.

(1)Write the names of everyone in your household not entered in 1B. Households with foster and non-foster children may choose to include the foster child(ren) as household members, as well as any personal income earned by the foster child(ren), on the same household application that includes the non- foster child(ren).

(2)Write the amount of the income received on a yearly basis for each household member. The income may be for the current month, the amount projected for the first month the application is made for, or for the month prior to application. This income is the amount before taxes or any deductions are made. Also, indicate the source of the income. Refer to examples below for income to report.

PART 3 – MEDICAID AND STATE CHILDREN’S HEALTH INSURANCE PROGRAMS – Federal law allows the sharing of the information on this application with Medicaid and State Children’s Health Insurance Programs. At this time, no procedures are in place to share this information. Since the procedures to share this information with the Medicaid and State Children’s Health Insurance Programs may be established in the future, please indicate if you do not want this information to be shared. The Medicaid and State Children’s Health Insurance Programs can only use the information to identify children who may be eligible for free or low cost health insurance and to enroll them in either Medicaid or the State Children’s Health Insurance Program. They are not allowed to use the information for any other purpose. If this information is not shared, it will not affect the eligibility of your child(ren) for free or reduced-price meals. If you do not want to share the information with the Medicaid and State Children’s Health Insurance Programs, please indicate this decision by entering a check.

PART 4 – SIGNATURE AND SOCIAL SECURITY NUMBER: All households complete this part.

(1)All income eligibility statements must have the signature of an adult household member.

(2)The adult household member who signs the statement must include the last four digits of his/her Social Security Number. If he/she does not have a Social Security Number, write "none". If you listed an ACCENT case number for Supplemental Nutrition Assistance Program or Families First cash assistance, or a case number for Families First Child Care Assistance, the last four digits of the Social Security Number are not needed.

(3)The income eligibility application is valid for one calendar year from the date of the signature of the Determining Official. You will be contacted by the staff of the child care institution serving your child(ren) to update the information contained in this application before the close of the eligibility period. The staff of the child care institution is required to verify and certify the eligibility of your household every 12 months. Section 9 of the National School Lunch Act requires that, unless the participant's Supplemental Nutrition Assistance Program or Families First case number is provided, you must include the last four digits of the Social Security Number of the household member signing the statement or an indication that the household member signing the statement does not possess a Social Security Number. Provision of the last four digits of a Social Security Number is not mandatory, but if this Social Security information is not provided or an indication is not made that the adult household member signing the statement does not have a Social Security Number, the statement cannot be approved.

PART 5 - RACIAL/ETHNIC IDENTITY: You are not required to answer this question to receive meal benefits. However, this information will help ensure that everyone is treated fairly.

Definition of Ethnicity: Hispanic or Latino means a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Definition of Race: American Indian or Alaskan Native means a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. Asian means a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American means a person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander means a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White means a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)

No person shall be excluded from participation in, be denied benefits of, or be otherwise subjected to discrimination in the CACFP on the grounds of race, color, sex, age, disability, national origin, or any other classification protected by Federal, Tennessee State constitutional, or statutory law.