Child Care Food Program Form

Child's Name
Hidden
Center Name & Address
Hidden
Please read the instructions and accompanying Parent Letter before completing this form. If you need assistance completing this form, call:

Step 1
Complete the following table for all INFANTS and CHILDREN through age 18 that reside in the household, even if not related. (include child listed at top of form)
Child’s Name

(Last Name, First Name)
Date of Birth
MM slash DD slash YYYY
Attends this center?
- Yes
- No
Foster Child?
- Yes
- No
Migrant
- Yes
- No
Homeless/Runaway?
- Yes
- No
Child’s Name

(Last Name, First Name)
Date of Birth
MM slash DD slash YYYY
Attends this center?
- Yes
- No
Foster Child?
- Yes
- No
Migrant
- Yes
- No
Homeless/Runaway?
- Yes
- No
Child’s Name

(Last Name, First Name)
Date of Birth
MM slash DD slash YYYY
Attends this center?
- Yes
- No
Foster Child?
- Yes
- No
Migrant
- Yes
- No
Homeless/Runaway?
- Yes
- No
Child’s Name

(Last Name, First Name)
Date of Birth
MM slash DD slash YYYY
Attends this center?
- Yes
- No
Foster Child?
- Yes
- No
Migrant
- Yes
- No
Homeless/Runaway?
- Yes
- No

Step 2
Do any household members (children or adults) receive Food Assistance Program (FAP/SNAP) or Temporary Assistance for Needy Families (TANF) benefits?...

If NO, go to STEP 3. If YES, enter one of the following case numbers, then go to STEP 5.
FAP/SNAP Case Number
FAP Case Number 1
FAP Case Number 2
FAP Case Number 3
FAP Case Number 4
FAP Case Number 5
FAP Case Number 6
FAP Case Number 7
FAP Case Number 8
FAP Case Number 9
FAP Case Number 10
TANF Case Number
TANF Case Number 1
TANF Case Number 2
TANF Case Number 3
TANF Case Number 4
TANF Case Number 5
TANF Case Number 6
TANF Case Number 7
TANF Case Number 8
TANF Case Number 9
TANF Case Number 10

Step 3
Children’s Income Information (see reverse side for what types of income to report) (skip this step if you listed a case # in STEP 2)
Sometimes children earn or receive income. Enter the total income received by all children listed in STEP 1, then check how often the income is received.
Children’s income – Total:
How often received?
- Weekly
- Bi-Weekly
- Twice a Month
- Monthly
- Annually

Step 4
Household income and adult household member information (see reverse side for what types of income to report) (skip this step if you listed a case # in STEP 2)…
Adult Household Members and Income
list all adult household members (age 19 and up) even if they do not receive income. For each adult, list the total gross income (before taxes & deductions) from each source in whole dollars only (no cents) and how often it is received (i.e., weekly, bi-weekly, twice a month, monthly, or annually). For an adult that does not receive income from any source, write “none” or “0.” If you enter “none” or “0” or leave any income fields blank, you are certifying that there is no income to report.
Adult Household Member’s Name

(Last Name, First Name)
Earnings from Work ($ Amount / How often?)

Weekly Biweekly Monthly Twice a Month Annually
Public Assistance/Child Support/Alimony ($ Amount / How often?)

Weekly Biweekly Monthly Twice a Month Annually
Pensions/Retirement/All Other Income ($ Amount / How often?)

Weekly Biweekly Monthly Twice a Month Annually
Adult Household Member’s Name

(Last Name, First Name)
Earnings from Work ($ Amount / How often?)

Weekly Biweekly Monthly Twice a Month Annually
Public Assistance/Child Support/Alimony ($ Amount / How often?)

Weekly Biweekly Monthly Twice a Month Annually
Pensions/Retirement/All Other Income ($ Amount / How often?)

Weekly Biweekly Monthly Twice a Month Annually
Total Household Members (Add STEP 1 & 4)
Last four digits of Social Security Number (SSN) of adult household member
If no SSN, write “none.”
SSN 1
SSN 2
SSN 3
SSN 4

INSTRUCTIONS for completing the Free and Reduced-Price Meal Application

IF ANY MEMBER OF YOUR HOUSEHOLD RECEIVES FOOD ASSISTANCE PROGRAM (FAP/SNAP) OR TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) BENEFITS, FOLLOW THESE INSTRUCTIONS: STEP 1: List all children age 18 and under that are supported with the household’s income, even if they are not related to you. Be sure to include the child listed at the top of the form. If there is not enough space to list all children, use a second form and attach the forms together. List the date of birth of each child. In the next three columns, circle Yes or No to answer each question for each child listed. STEP 2: Enter either the FAP/SNAP or TANF case number in the designated space. The case number will be on your letter of eligibility; it is not the number on your EBT card. STEP 3: Skip this step. STEP 4: Skip this step. STEP 5: Enter your address and phone # (if available). An adult household member must sign the form. Print the name of the person who signed the form, then enter the date signed.

IF YOU ARE APPLYING FOR A FOSTER CHILD, FOLLOW THESE INSTRUCTIONS: With appropriate documentation, foster children are automatically eligible for free meals regardless of the income of the household where they reside. You have the option to provide the child care center with official documentation from the foster care agency or court that placed the child in the household, rather than completing this application. Should you choose to complete this application, and you are applying only for a foster child(ren), then only complete STEPS 1 and 5. If you are applying for foster and non-foster children, complete STEPS 1, 3, 4 and 5. If completing STEP 3, do not include payments to the household for the care of the foster child(ren). See the instructions listed below for the applicable steps.

ALL OTHER HOUSEHOLDS, FOLLOW THESE INSTRUCTIONS: STEP 1: List all children age 18 and under that are supported with the household’s income, even if they are not related to you. Be sure to include the child listed at the top of the form. If there is not enough space to list all children, use a second form and attach the forms together. List the date of birth of each child. In the next three columns, circle Yes or No to answer each question for each child listed. STEP 2: Skip this step. STEP 3: Enter the total income received by all children listed in STEP 1, then check how often the income is received. STEP 4: List all adults age 19 and older that are supported with the household’s income, even if they are not related to you and even if they receive no income. If there is not enough space to list all adults, use a second form and attach the forms together. For each adult, list the amount of income he/she regularly receives before taxes or anything else is taken out and circle how often the income is received (frequency) in the appropriate columns. If self-employed, list net income. See examples below for sources of income to report. For any adult with no income, write “none” or “0.” Any income fields that are blank will also be counted as a zero (0). Enter the total number of household members (all children and adults), then list the last four digits of the social security number (SSN) of the adult completing/signing the application (or write NONE if he/she has no SSN). STEP 5: Enter your address and phone # (if available). An adult household member must sign the form. Print the name of the person who signed the form, then enter the date signed.

Sources of Income for Children

Earnings from work	A child has a regular full or part-time job where they earn a salary or wages
Social Security Disability Payments Survivor’s Benefits	A child is blind or disabled and receives Social Security benefits A parent is disabled, retired, or deceased, and their child receives Social Security benefits
Income from person outside the household	A friend or extended family member regularly gives a child spending money
Income from any other source	A child receives regular income from a private pension fund, annuity, or trust

Sources of Income for Adults

Earnings from Work

Public Assistance/ Alimony/Child Support

Pensions/Retirement/All Other Income

Salary, wages, cash bonuses
Net income from selfemployment (farm or business)

If you are in the U.S. Military:

Basic pay and cash bonuses (do NOT include combat pay, FSSA or privatized housing allowances)
Allowances for off-base housing, food and clothing

Unemployment benefits
Worker’s compensation
Supplemental Security Income (SSI)
Cash assistance from State or local government
Alimony payments
Child support payments
Veteran’s benefits
Strike benefits

Social Security (including railroad retirement and black lung benefits)
Private pensions or disability benefits
Regular income from trusts or estates
Annuities
Investment income
Earned interest
Rental income
Regular cash payments from outside household

;

The Richard B. Russell National School Lunch Act requires that, unless you list a current Food Assistance Program (FAP/SNAP) or Temporary Assistance for Needy Families (TANF) case number or are applying for a foster child, you must include the last four digits of the Social Security Number (SSN) of the adult household member signing the application or indicate that the signer does not have a SSN. Providing the last four digits of a SSN is not mandatory, but if this information is not given or an indication is not made that the signer does not have a SSN, the application cannot be approved. The information provided on this form may be verified through program reviews, audits, and investigations and may include contacting employers to determine income, contacting a welfare office to verify receipt of FAP/SNAP or TANF benefits, contacting the state employment security office to determine the amount of benefits received, and checking any documentation produced by the household to prove the amount of income received. These verification efforts may result in a loss or reduction of benefits, administrative claims, or legal actions if incorrect information is reported. We may share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs; auditors for program reviews; and law enforcement officials to help them investigate violations of program rules.

This institution is an equal opportunity provider. Please refer to the accompanying Parent Letter to read the full Nondiscrimination Statement

Step 1

Step 2

Step 3

Step 4

Step 5

Optional: Child’s ethnic and racial identities

For Contractor Use Only

INSTRUCTIONS for completing the Free and Reduced-Price Meal Application

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