Form Nsd 3101 – Fill Out and Use This PDF

FOR MEAL BENEFITS IN CHILD CARE:

Name of Child Care Center:

2. FOSTER CHILDREN: (See the instructions). If this is a foster child, check here  and write the child’s monthly

3.OTHER BENEFITS: If you are getting Food Stamp, CalWORKs, Kin-GAP, or FDPIR benefits for your child, list the case number. DO NOT complete Section #4. Go to Section #5.

Food Stamp Case Number:

FDPIR Case Number:

CalWORKs Case Number:

Kin-GAP:

4.ALL OTHER HOUSEHOLDS: (Complete this section only if you did not complete Sections #2 or #3.) List all household members. List all income. Go to Section #5.

5.SIGNATURE AND SOCIAL SECURITY NUMBER:

PENALTIES FOR MISREPRESENTATION: I certify that all of the above information is true and correct and that the Food Stamp, CalWORKs, Kin-GAP, FDPIR, or other eligible program case number is current, correct, or that all income is reported. I understand that this information is being given for the receipt of Federal funds; that agency officials may verify the information on the Meal Benefit Form and that the deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws.

Signature of Adult:

Privacy Act Statement: Unless you list the child's Food Stamp, CalWORKs, Kin-GAP, or FDPIR 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 form, or indicate that the household member signing the form 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 the “Check here if no Social Security Number” is not marked, we cannot approve the form. The social security number may be used to identify the household member in verifying the correctness of the information stated on the form. This may include program

reviews, audits and investigations, and may include contacting employers to determine income, contacting a Food Stamp, CalWORKs, Kin-GAP, or FDPIR office to determine current certification for Food Stamp, CalWORKs, Kin-GAP, or FDPIR 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. The social security number may also be disclosed to programs as authorized under the National School Lunch Act and the Child Nutrition Act, the Comptroller General of the United States, and law enforcement officials for the purpose of investigating violations of certain Federal, State, and local education, and health and nutrition programs.

6.RACIAL/ETHNIC IDENTITY: You are not required to answer these questions. If you choose to do so, please mark one or more of the following racial identities:

In accordance with Federal law and U.S. Department of Agriculture policy, this agency is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability.

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

DESCRIPTION OF RACIAL AND ETHNIC CATEGORIES

The federal government has established the following five racial categories and one ethnic category:

RACIAL:

American Indian or Alaska Native -- A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

Asian -- 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 -- A person having origins in any of the black racial groups of Africa. Terms such as "Haitian" or "Negro" can be used in addition to "Black or African American."

Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White -- A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

ETHNIC:

Hispanic or Latino -- A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, "Spanish origin" can be used in addition to "Hispanic or Latino."