Form Spi Cacfp 1269E Iea – Fill Out and Use This PDF

Child and Adult Care Food Program

ENROLLMENT/INCOME-ELIGIBILITY APPLICATION

PART 1 - CHILDREN’S INFORMATION—Required for all children in care

Child’s Name		Circle Normal Days/						Circle Meals and
	Birthdate Age	Print Normal Hours of Care					Snacks Normally Received
		Sun Mon Tu Wed Th Fri Sat					Breakfast	A.M. Snack	Lunch
		Normal Hours		to			P.M. Snack	Supper	Eve. Snack
		Sun Mon Tu Wed Th Fri Sat					Breakfast	A.M. Snack	Lunch
		Normal Hours		to			P.M. Snack	Supper	Eve. Snack
		Sun Mon Tu Wed Th Fri Sat					Breakfast	A.M. Snack	Lunch
		Normal Hours		to			P.M. Snack	Supper	Eve. Snack
		Sun Mon Tu Wed Th Fri Sat					Breakfast	A.M. Snack	Lunch
		Normal Hours		to			P.M. Snack	Supper	Eve. Snack

INCOME ELIGIBILITY

Please check the boxes that apply to help determine the other parts of this form to complete:

A family member in our household receives benefits from Basic Food, TANF, or FDPIR. (Please complete Part 2 and 5.)

One or more of the children in Part 1 is a foster child. (Please complete Part 3 and 5.)

My child(ren) may qualify for Free/Reduced-Price meals based on household income. (Please complete Part 4 and 5.)

My child(ren) will not qualify for Free/Reduced-Price meals. (Please complete Part 5 only.)

PART 2 – HOUSEHOLD MEMBER RECEIVING BASIC FOOD, TANF, OR FDPIR—Only one household member receiving

benefits must be listed in order to establish eligibility for all children in the household.

Name	Circle One	Case Number or Identification Number
Basic Food	TANF	FDPIR

PART 3 - FOSTER CHILDREN—List the names of any children listed in Part 1 who are foster children

PART 4 - TOTAL HOUSEHOLD INCOME FROM LAST MONTH—Not required if you have reported a case number in Part 2 Gross Income from Last Month (if None, Write ―0‖)

(or net income if self-employed)

List Names (First and Last) of everyone in your	Earnings from	Alimony,	Retirement,	Job Two or
	Work Before	Child Support,	Pensions,	Any Other
household, including foster children	Deductions	Welfare	Social Security	Income

1.

2.

3.

4.

5.

6.

7.

PART 5 - SIGNATURE AND CERTIFICATION - REQUIRED

The adult household member who fills out the application must sign below. If Part 4 is completed, the adult signing the form must also list the last four digits of his/her Social Security Number or check the “I do not have a Social Security Number” box. (See Privacy Act Statement on the back of

this page.) If you have listed a case number in Part 2 or are applying on behalf of a foster child, or have checked the box that your child(ren) will not qualify for Free/Reduced-Price meals, the last four digits of the Social Security Number is not needed.

I certify that all of the above information is true and correct and that all income is reported. I understand that this information is being given for the receipt of federal funds; that institution officials may verify the information on the application; and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws.

Signature of Adult	Date	Print Name of Adult Signing	I do not
			have a Social
		Social Security Number (last four digits)	Security
		XXX-XX-	Number

FORM SPI CACFP 1269E/IEA (Rev. 5/11)	Page 1	OSPI/Child Nutrition Services
		Attachment 2 to Bulletin No. 024-11 CNS
		June 10, 2011

PART 6 – CHILDREN’S ETHNIC AND RACIAL IDENTITIES—You are not required to answer this part.

Check the ethnic and racial category of your child. We need this information to be sure that everyone receives benefits on a fair basis.

Ethnicity:
Hispanic or Latino	No child will be discriminated against because of race,
Not Hispanic or Latino	color, national origin, gender, age, or disability.
Race:
White
Black or African American
Asian
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander
Multi-Racial

If you feel you have been discriminated against, you should write USDA, Director of Civil Rights, 1400 Independence Avenue SW, Washington, DC 20250-9410.

PRIVACY ACT STATEMENT

The Richard B. Russell National School Lunch Act requires that, unless a household member’s Basic Food, TANF, or FDPIR case number is provided or you are applying on behalf of a foster child, you must include the last four digits of the Social Security Number of the adult household member signing the application, or indicate that the household member does not have a Social Security Number. Provision of the last four digits of the Social Security Number is not mandatory, but if the last four digits of the Social Security Number is not provided or an indication is not made that the signer does not have a Social Security Number, the application cannot be approved in the free or reduced-price category. This notice must be brought to the attention of the household member whose last four digits of the Social Security Number is disclosed. The last four digits of the Social Security Number may be used to identify the household member in carrying out efforts to verify the correctness of information stated on the application. These verification efforts may be carried out through program reviews, audits, and investigations and may include contacting employers to determine income, contacting a Basic Food or welfare office to determine current certification for receipt of Basic Food 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.

CENTER USE ONLY

Foster child(ren) have been identified on this form and qualify for the free category.

Child(ren) on this form who are not foster children qualify as follows:

This form must be signed and dated by the institution’s representative.

	Signature of Institution’s Representative		Date

FORM SPI CACFP 1269E/IEA (Rev. 5/11)	Page 2	OSPI/Child Nutrition Services
		Attachment 2 to Bulletin No. 024-11 CNS
		June 10, 2011