CHILD AND ADULT CARE FOOD PROGRAM: CHILD CARE COMPONENT INCOME ELIGIBILITY APPLICATION FOR FREE AND REDUCED-PRICE MEALS Fiscal Year 2018-2019 INSTRUCTIONS: To apply fr fee and reduced-price meals, read the household Later and intructons on backside offs farm Complete application and refurn tothe centr. In accordance with the NSLA, information on this application may be disclosed to other Chil Nutriton Programs or applicable ‘enforcement agencies, Parensiguardians are not required to conser this clscosure. Part 7's to be completed by all houssholcs, Part 2 eto be used only for a chil iving in a household receiving food assistance (SNAP) or Ohio Works First (OWF) benef's. Part 3's only fr children NOT receiving Food. ‘Assistance or OWF benefits. Pat 4 an adult household member must sign and date form; the last 4 digits of social Security number must be Isted if Pat 3 ie ‘completod, Part Sis optional, “Asterisks indicate ino that must be comsleted. Form must be completed annually ard valid for only 12 months, CHECK] PART 2 — LIST EACH CHILD'S FOOD ASSISTANCE CENTER NAME ssroster | (chap) OR OWF CASE NUMBER, F ANY. VALID (Git, | Ease numBeR contaNs'7 or fa, 60 NOT LIST SIMPE_ PART = PRINTINEORMATION FOR ALL CHILDREN ENROLLED AT CENTER | resmtityer | CARD NUMBER. €00..numbere net val setimesotey [Chzek yoe 17 FOOD ASSISTANCE (SNAPY or “NAME OF ENROLLED CHILD(REN) AGE | enmioare | eur : oO 2 1 [essen 3 O CASE NO. 4 TT easeno 'PART 3 TOTAL HOUSEHOLD SIZE, TOTAL HOUSEHOLD GROSS INCOME AND HOW OFTEN IT WAS RECEIVED: List names ofall household ‘members List all gross income: ist how much and how often. If Part 2's completed, skip to Part 4. OHIO WORKS FIRST (OWF) ‘8. UST NAMES OF ALL s.chick | 6 GROSS INCOME during the lat month (amount earned befor taxes & other deduations) and HOUSEHOLD MEMBERS if” HOW OFTEN IT WAS RECEIVED: Waeky, Every 2 Weeks, Twice Per Mont, Monthy, Annually INCLUDING CHILOREN NOZERO | 1 Eamegs tomverk | 2 Welaepaynens, | 3 Persons, rremen, 4 Al ter hours USTED ABOVE IN PART 1 eloweseevetore | Chidetppo, sony Sonal Sent, $5, UA EXAMPLE: JANE SMITH | [ys 200s week'y $150 1 twice month | $ 100 / monthly | § 1 Cl ls po 5 _ 2 [ar a a ay 8 8 n eg [pris eae 8 L 4 Cy Ts. L 8 8 5. Os L 8 8 L 7 Ly ts. 3 3 PART 4 SIGNATURE & LAST 4 DIGITS OF SOCIAL SECURITY NUMBER: Adult houschold member must sign/date form. Part 3 le completed, ‘the adult signing the form must also list last 4 digits of his/her Social Security Number or check the “Ido not have a Soctal Security Number” box. | cetity that al nformation on this fom is rue and correct and tha ll income is reported. | understand thatthe center wil get Federal Funds based on the infermation. l understand that CACEP officials may vey the infermation. | understand that | purposely give fale information, Imay be prosecuted. © ifPart 3 ie completed, insert last 4 digits of Social Security Number To) (Steet tappeabi) SIGNATURE OF ADULTHOUSEHOLD MEMBER | DATE I do not have a Social Security Number Print Name: Daytime Phone Number: ‘Work Phone Number ‘Street Apt “Cly (State | Zip: cour PART 6: RACIALIETHNIC IDENTITY (Optional): Please check appropriate boxes to identify the race and ethnicity of enrolled child(ren). ‘American indian or Alaska Native Asian Black or African American | Netive Hawaiian or Other Pacific Islander White z Other Please mark one ethnic identi Hispanic or Latino [5 Not Hispanic or Latino Prvazy Act Sateen Tha Rehers 8 Rossel National Schoo Lansn Act reqs ia Fromavan oy appoatin, You dona heve Tove ha Woman POT oroTee ‘wo cannot approve the participa er ioe or reduces pice meals, You moat nce th lat ours of he Soci Socurty Number oe sh hows rember who sare he “pvleaton, The Socal Securty Nabe lsat eguted when you apply on beh o's fcr cH cr you tnt « SuplomentalTestiton Aasblance Progr (GNAP). Temrary ‘esitace fr Needy Fama (TANF Programe Food Datbuion Program on Ind Reserve (FDPIR) care nue eho patspan or ler (FOPIR) seo when ye ‘deat thatthe ast household menber signa tie apteson does nt have 8 Socal Sanrky NenBer We wit yea Yur infarmaton to determine # te panpat akg or tee ceredventpres mes, sor adnan and etoremart he roger, State Distribution: 7/13/2018 TH SECTION 10 BE COMPLETED EY CENTER Tote_Al formation stove Wi scTon isto be Mad inby s paanT orga angi oman owen ¥ aac) by Roush eons Par’) AppkesionCeriaCaepetad a Forts tl ured sce, carpe tl hao near oa USDA nes gy Sues aoa Cikelreet ome coveccaegaton, Won hemes ad nite feqaraae | 2 FREE:Dasedon fond AsearcloWF Cam cipay ian. yourat comer a en to amualncone bet detemaion Use 2 Howetn ‘abvng amu ncone comersen Wiel Coy Weak an 125, Toe pat Month nin 24 Monty 12__ | REGUGED bated on Houreol Se & hoon Total ‘Total Household Iaemat & 1 PADD, based on 1 Income Too High Household © Incomplete ace Por oWeek cEvey 2 Weeks o Twice Per Month c Month o Year 8 Invaldeate number er tomation ‘Signature of Sponsor] Center Representative Date Sponsor CerfiedCalegorized Form Effective Dale Expiration Dale a thc a diay pre ore som a cen CONS kon (Poni ttre sos) yuo mon nin CON Revised 6/2018 2HOUSEHOLD LETTER - Dear Parent or Guardian Please help us comply with the requirements of the United Stetes Department of Agriculture's Child and Adult Care Food Program (CACFP) by completing the tached income eligibility application for ree and reduced-price meas. Al infermation willbe treated with srt confidentially. The CACFP provides reimbursement tothe childcare center for heathy meals and snacks served to children ervclied in child care. The completion of the income eligibility ‘application is optional. Complete the application on the reverse side using the instructions below for your type of household. You or your eile do ot have to De U.S. citzene to qualy for meal benef offered a he chidl care carter. Households wth incomes less than of equa othe reduoe price values listed on the char atthe botiom ofthis page are eligible for free meal benef. An application must cortan complete information to be cansidered for free or reduced-price ‘meals, Housoholds are no longer required to report changes regarding the noase or decrease of income or household sizeof when the house held is no longer ‘ete eligible for food assistance (SNAP) or Onio Works First (OWF), Once approved fo ree reduced-price benefits, @ househoid will remain elgle fo these benefits fora period not to exceed 12 months. During petiod of unemsloymert, your chien) is elgibe for meal reimbursement provided the ls of income during this tine causes the famiyto be within elgbilty standards fr meals. in Operation of the CACFP, no person Wal be diseriminated against because of race, color, national origin, eex, ape or deablity §226.23(}(2)Wv). If you have quceions regarding the completion ofthis application, contac the chi care center. PART 1=CHILD INFORMATION: ALL HOUSEHOLDS COMPLETE THIS PART (“denotes required info) ‘+ Print the name of the chilren) enrolled atthe child care center. Al children (including foster citen) can be listed on the same application + Uist the enrolled chiles age and bith dat, + Check box indicating fhe chid isa foster chi. Foster children that are under the legal responsiblity ofthe foster care agency or court are eligible for ‘tee meals. Any foster child in the household is eligible for free meals regardless of income. PART 2 HOUSEHOLDS RECEIVING FOOD ASSISTANCE OR OHIO WORKS FIRST: COMPLETE THIS PART AND PART 4 Ifa child is a member of a {food assistance (SNAP) or OWF household, they are automaticaly eligible to recoive free CACFP meal benefits. ‘Circe the type of deneft received: Food Assistance (SNAP) or Ohio Works First (OWE) * sta curren food assistance or OWF case number for each chi, Thi wil bea 7 o& 10-dgit number. Do not lit spe card number SSkIP PART 3 ~ Do no st names of household members or income if you lista a vale Food Assistance (SNAP) or OWF cage number for each child in Part 2 PART 3 TOTAL HOUSEHOLD SIZE, GROSS INCOME AND HOW OFTEN RECEIVED: ALL OTHER HOUSEHOLDS COMPLETE PARTS 2 & 4, '8) Write the names ofall houschold members including yourself and the children) that attends the chi eare center, nating eny income received. A household is defined asa group of elated or unrelated Incivduals who are ving a6 one economic uit that share housing andlor sigicart income and ‘expenses of ils members. This might include grandparents, other relatives, or rends who ive wih you. Atach another eve of paper if you need more Space to lst all household members, 1) Check the box for any person listed asa household member (iclucng children) that has no income, ©} Foreach household member lst each hype of income received during the last morth and list haw often the money was received. 1. Earrings from work before deductions: Wrte the amount of total gross income each household member received the last month, before ‘exesideductions or anything ele Is taken out (nt the take-home pay) and how often f Was received (Weekly. every to weeks, wice per month, ‘monthly, annual). Income is any money received on a recuring basis, incusing gross earned income. Households are not requled to Include payments received {or 2 foster chid as income. I any amount during the previous month was more or loss than Usual, rte that person's usual ‘monthly income. If you normally get overtime. include i, but nol you only get it sometimes. f you are inthe miltary and your housing is prt ofthe Military Housing Privatization Intitve and you recaive the Family Subsistence Supplemental Allowance, do nat include thee allowances as income, ‘Aso, n regard to deployed service members oly that portion ofa deployed service members income made available by them or on thelr bel to the Pousehold wil be courted as income tothe household. Combat pay, cluding Deployment Extension Inentive Pay (OEIP) is lao excluded and \will pot be counted as income to the household. All ether allowances must be insuded in your gross income. 2, _Listthe amount each person got the last month ftom welfare, chid support or alimony and lst how often the money was received 3. List the amount each person got the last month from pensions, retirement, Social Securty, Supplemental Securly Income (SS), Veteran's (VA) berefis or cisabilty benefits and list how often the money wae received 4. Ustall other income sources. Examples include: Wotker’s Compensation, strike benefts, unemployment compensation, reguiar contributions trom people who do not lve in’ your household, cash withdrawn from savings, interestidvdends, income from esiatestrustslinvestments, net Foyatiestannuties or any over income. Sel-omployed applicants should teport income sft expanses (net income) in column 1 under earings ‘rom work. Business, farm or rental property report income should be entered in column 4. Do not include food assistance payments. PART 4 ~ SIGNATURE AND LAST 4 DIGITS OF SOCIAL SECURITY NUMBER: ALL HOUSEHOLDS COMPLETE THIS PART ("denotes required info) '2)Allapplications must have the signature of an adult household member. 5) + The adult signing the application must also date the form. ©) * Only an application that sts income in Part 3 must have the last four digits of he socal security number of the adult who signs. Ifthe adult does not have a social security number, check the box marked, “Ido not have a Socal Secutty Number.” Ifyou Isted a food assistance or OWF number for teach chid or ifyou are applying fora foster chi, the last four digits of the socal secirly number are not required PART 5 ~ RACIAL/ETHNIC IDENTITY ~ OPTIONAL. ‘You are not requted lo answer this pat inorder forthe application tobe considered complete, This information is collected to make sure that everyone is treated {ary and wil be kept confidential. No child wil be ciscrminated against because of race, color, national origin, gender, age or disablty. NON-DISCRIMINATION STATEMENT: in accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programe are prohibited from Aiscriminating based on race, color, national origin, sex, disabliy, age, or reprisal or relalation for prior elvl rights activity in any program or activity Conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.9. Braille, large print, audiotape, American Sign Language, etc), should contact the Agency (State or local) where they applied for benefits. Individuals who are deat, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To fle a program complaint of diserimination, complete the USLA Prosram Discrmnaton Complain 01m, (AD-3027) found online at: | io Fic a Complaol, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested inthe form. To request a copy of the complaint form, call (866) 632-9982. Submit your complated form of letter to USDA by: (1) mail: US, Depariment of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250- 9410; (2) fax: (202) 680-7442; or (3) email: pyocram jriske@us4a ov. This institution is an equal opportunity provider. REDUCED INCOME ELIGIBILITY GUIDELINES ~ 185% Guidelines to be effective from July 1, 2018 through June 30, 2019 Households with incomes less than or equal tothe reduced:price values below are eligible for free or reduced-price meal benefits. HOUSEHOLD SIZE YEAR MONTH TWICE PER MONTH EVERY TWOWEEKS WEEK 1 22489 1872 536 864 432 2 30.051 2.538 4268 172 586 3 38.443 3.204 ‘iso taro 740 4 46436 3870 41336 1786 83 5 baer 4.536 2268 1.047 6 eaarg 5.202 201 i201 7 raat 5.808 34 11355 8 78.403 6534 41508 For each addtional family member, ad 7.992 666 383 308 154 OCN Revised 8/2018 10