Form Nsd 3101 PDF Details

In the efforts to ensure equitable access to meal benefits under the Child and Adult Care Food Program (CACFP), the California Department of Education's Nutrition Services Division provides the NSD 3101 form, a crucial document for the fiscal year 2009-2010. This form, revised in March 2007, serves as a comprehensive application designed to accurately assess and grant meal benefits for children within various care settings. Essential components of the form include sections dedicated to child information, where the names and details of children applying for benefits are listed; specific directions for foster children that streamline their approval process; provisions for households receiving benefits such as Food Stamps, CalWORKs, Kin-GAP, or FDPIR by only requiring case numbers; and a detailed income reporting section for all other households. The form sternly necessitates honest reporting of household income and the signature of an adult household member, underlined by warnings of penalties for misrepresentation, highlighting the importance of integrity in the process. Additionally, it touches on privacy concerns with respect to the provision of Social Security numbers and lays out the procedure for their use in verification processes. The form also inclusively asks for voluntary racial/ethnic identity information, reinforcing the program's commitment to nondiscrimination in accordance with Federal law and U.S. Department of Agriculture policy. Lastly, for thorough guidance, the form concludes with instructions on its completion, ensuring applicants are well-informed on how to proceed accurately, thereby facilitating a smoother review and decision-making process by the CDE officials.

QuestionAnswer
Form NameForm Nsd 3101
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesnsd 3101 cacfp 29 rev 8 2018 in spanish, nsd 3101, nsd3101, USDA

Form Preview Example

CALIFORNIA DEPARTMENT OF EDUCATION

 

 

CHILD AND ADULT CARE FOOD PROGRAM

NUTRITION SERVICES DIVISION

 

 

 

NSD 3101 (REV. 03/07)

 

MEAL BENEFIT FORM FOR YEAR

 

2009-2010

 

 

Complete, sign, and return the form to

 

 

 

.

Please read the instructions. If you need help completing this form, call:

.

1. CHILD INFORMATION:

 

 

 

 

 

CHILD’S NAME:

 

 

 

 

 

 

Last

First

 

M.I.

CHILD’S NAME:

 

 

 

 

 

 

Last

First

 

M.I.

CHILD’S NAME:

 

 

 

 

 

 

Last

First

 

M.I.

CHILD’S NAME:

 

 

 

 

 

 

Last

First

 

M.I.

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

personal use income here: $

 

. Go to Section #5.

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.

NAMES

 

 

CURRENT MONTHLY INCOME

 

 

 

 

 

 

 

 

MONTHLY EARNINGS

MONTHLY WELFARE,

MONTHLY PAYMENTS

MONTHLY EARNINGS

NAMES OF HOUSEHOLD MEMBERS

FROM PENSIONS,

FROM JOB 2 OR ANY

FROM WORK (BEFORE

 

CHILD SUPPORT,

(INCLUDE THE CHILDREN LISTED ABOVE)

 

RETIREMENT,

OTHER MONTHLY

DEDUCTIONS) JOB 1

 

ALIMONY

 

 

SOCIAL SECURITY

INCOME

 

 

 

 

 

 

 

 

 

 

1.

$

$

 

$

$

2.

$

$

 

$

$

3.

$

$

 

$

$

4.

$

$

 

$

$

5.

$

$

 

$

$

6.

$

$

 

$

$

7.

$

$

 

$

$

8.

$

$

 

$

$

9.

$

$

 

$

$

10.

$

$

 

$

$

11.

$

$

 

$

$

CALIFORNIA DEPARTMENT OF EDUCATION

CHILD AND ADULT CARE FOOD PROGRAM

NUTRITION SERVICES DIVISION

NSD 3101 PAGE 2 (REV. 03/07)

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:

 

 

 

 

 

 

 

 

 

 

 

 

Check here if no

Social Security Number:

 

 

 

 

Social Security Number

Printed Name:

 

 

 

 

 

 

 

Home Phone:

 

 

Work Phone:

 

 

Home Address:

 

 

 

 

 

 

 

City:

 

 

 

State:

 

Zip Code:

 

Date:

 

 

 

 

 

 

 

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:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

 

Please mark one of the following ethnic identities:

Hispanic or Latino

Not Hispanic or Latino

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.

For Official Use Only:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

For CDE Only

 

 

 

 

 

 

 

 

 

Food Stamp/CalWORKs/Kin-GAP/FDPIR household categorically eligible free:

 

 

 

MONTHLY INCOME CONVERSION: WEEKLY X 4.33, EVERY 2 WEEKS X 2.15, TWICE A MONTH X 2

 

 

 

 

 

 

 

Total monthly income:

____________

Household size: ________

 

 

 

 

 

 

 

Eligibility Classification:

Free

Reduced Price

 

Paid

 

 

 

 

 

 

Determining official (print name):

 

 

 

 

 

 

 

 

 

 

Signature:

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

CALIFORNIA DEPARTMENT OF EDUCATION

CHILD AND ADULT CARE FOOD PROGRAM

NUTRITION SERVICES DIVISION

NSD 3101 PAGE 3 (REV. 03/07)

HOW TO COMPLETE THE MEAL BENEFIT FORM

Please complete the Meal Benefit Form using the instructions below. Sign the form and return it to:

. If you need help, call:

1.CHILD INFORMATION:

a)Print your child’s name.

B) INCLUDE THE NAME OF THE CHILD CARE CENTER.

2.FOSTER CHILDREN: Complete this Section and sign the form in #5.

a)Write the foster child’s monthly “personal use” income. Write “0” if the foster child does not get “personal use” income.

b)A foster parent or other official representing the child must sign the form in #5. You do not have to list a Social Security Number.

c)Complete a separate form for each foster child.

3.OTHER BENEFITS: Complete this Section and sign the form in #5.

a)List your current Food Stamp, CalWORKs, Kin-GAP, or FDPIR case number(s) for your child(ren).

b)Sign the form in #5. An adult household member must sign. You do not have to list a Social Security Number.

4.ALL OTHER HOUSEHOLDS: Complete this Section and sign the form in #5.

a)Write the names of everyone in your household even if they do not have an income. Include yourself, your spouse, the child you are applying for, and all other household members.

b)Write the amount of income each person received last month before taxes or anything else was taken out and where it came from, such as earnings, welfare, pensions, and other income (see examples below for types of income to

report). Each income amount should be entered in the appropriate column on the form. If any amount last month was more or less than usual, write that person’s usual monthly income.

c)If anyone is self-employed, write the amount of income that person earns from self-employment. Please call the number listed at the top of the form if you need help.

d)Sign the form and include your Social Security Number in #5. If you do not have a Social Security Number, check the box “Check here if no Social Security Number.”

5.SIGNATURE AND SOCIAL SECURITY NUMBER:

a)The form must have a signature of an adult household member.

b)The adult household member who signs the statement must include his/her Social Security Number. If he/she does not have a Social Security number, check the box “Check here if no Social Security Number”. A Social Security Number is not needed if you listed a Food Stamp, CalWORKs, Kin-GAP, or FDPIR case number, or if you are applying for a foster child.

6.RACIAL/ETHNIC IDENTITY: You are not required to answer this question to get meal benefits, but completion of this information will help ensure that everyone is treated fairly.

Earnings from Work: Wages/salaries/tips Strike benefits

Unemployment compensation Worker’s compensation

Net income from self-owned business, day care business, or farm

Welfare/Child Support/Alimony Public assistance payments Welfare payments Alimony/child support payments

INCOME TO REPORT

Pensions/Retirement/Social Security

Pensions

Supplemental security income Retirement income

Veteran’s payments

Social Security

Other Monthly Income/Self-Employment

Disability benefits

Cash withdrawn from savings Interest dividends

Income from estates/trusts/investments Regular contributions from persons not living in the household

Net royalties/annuities/net rental income Military allowance for off-base housing Any other income

CALIFORNIA DEPARTMENT OF EDUCATION

CHILD AND ADULT CARE FOOD PROGRAM

NUTRITION SERVICES DIVISION

NSD 3101 PAGE 4 (REV. 03/07)

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."