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A. Child Income Sometimes children in the household earn or receive income. Please indicate the TOTAL income received by child household members listed in PART I here.
B. Other Household Members: List all household members even if they do not receive income. Also, list the adult participant if he/she did not meet eligibility in Part I. For each Household Member listed, if they do receive income, report total gross income (before taxes) for each source in whole dollars (no cents) only along with the frequency, i.e. twice a month, weekly, etc. If they do not receive income from any source, write ‘0’. If you enter “0” or leave any field blank, you are certifying (promising) there is no income to report.
C. Total Household Members (Adults and Children) listed in Part I and Part II:
D. Social Security Number. If Part II B is completed and household members are listed (with or without income), the adult completing the form must also list the last four digits of his or her Social Security Number or check the “I don’t have a Social Security Number” box below. (See Privacy Act Statement on next page). Failure to complete this section, if income is listed, will result in the denial of free or reduced eligibility.
I certify that all information on this form is true and that all income is reported. I understand that the center or day care home will get Federal funds based on the information I give. I understand that CACFP officials may verify the information. I understand that if I purposefully give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted. This signature also acknowledges that the child(ren) or adult listed on the form in Part I are enrolled for care. If not completed fully and signed, the participant will be placed in the Paid category.
Check (✓) one ethnic identity:
Check (✓) one or more racial identities:
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