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

Part 1 is required: for each child enter the Child's Name, Birthdate and Age, the Days of Attendance, and the Arrival Time and Departure Time.

Circle the Meals and Snacks Normally Received, and check Foster Child for a foster child.

Part 2: any household member receiving Basic Food/TANF/FDPIR in WA State can establish eligibility for children in the household. If listing case number or ID, please skip to part 5.

For WA State Recipients, a valid TANF or Basic Food number consists of seven to nine digits, such as 004235555. A parent may omit the zeros preceding the number and write as (ex. 4235555). It may start with 002, 003, 004, 005 or 05, does not include any letters, and is not a social security number (unless it's a tribal case number). It does not start with a 200 series number, is not a case number for state-paid childcare, and is not an EBT card number. DSHS Customer Service Number: (877) 501-2233. Basic Food and TANF website: www.washingtonconnection.org.

In Part 3, the adult signing the form must list the last four digits of their Social Security Number (SSN) or check the box if no SSN.

You must include the last four digits of the social security number of the adult household member who signs the application.

The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Basic Food, Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number.

List names (First and Last) of everyone in your household, including foster children, with their Annual Earnings from Work Before Deductions, their Annual Welfare, Alimony, Child Support and their Retirement, Pensions, Social Security, Other.

Annual Income Conversion by pay frequency: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly x 12.

Under Annual Earnings from Work Before Deductions enter salary, wages, cash bonuses, and net income from self-employment (farm or business).

Part 4, the children's ethnic and racial identities, is optional: responding to this section will not affect your children's eligibility for receiving meals during care.

For Ethnicity, check one: Hispanic or Latino or Not Hispanic or Latino.

For Race, check one or more: American Indian or Alaskan Native, Multi-Racial, Native Hawaiian or Pacific Island, Black or African American, Asian, White. In Part 3, enter the Number of Household Members and the Last 4 of SSN (check box if no SSN).

The certification: you certify (promise) that all information on this application is true and that all income is reported. If you purposely give false information, the participant/center may lose meal benefits, and you may be prosecuted under applicable State and Federal laws.

Under SIGN, enter the Signature, Print Name, Date, Address, City, State, Zip and Phone Number.

Do not fill out the section marked CENTER USE ONLY or OSPI USE ONLY.

Institution Representative Signature and Date, and Total Annual Income: INVALID WITHOUT SIGNATURE AND DATE.

The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, the funds your child care center/provider receives may be impacted.