J4TH CACFP 29 Meal Benefit Form for Children

Meal Benefit Form for Children
Just 4 Kids Preschool participates in California Department of Education's Child and Adult Care Food Program (CACFP). This is a program that augments the school's food program in providing nutritious and USDA regulated menu. Please fill out this form to avail and maximize the use of this program.

Please read the instructions when filling out this form. If you need help completing this form, call (760) 244-8280.
Name of Child Care Center
Note:
a. Print your child's name.
b. Indicate yes to the right of child's name if a foster child.

1. CHILD INFORMATION (List names of all children enrolled for care.)*

	Last Name	First Name	Middle Initial	Foster Child?
1
2
3
4

Are all child(ren) listed above foster child(ren)?*

All Foster Child(ren)Not All Foster Child(ren)

Notes:
a. List your current CalFresh, CalWORKs, or FDPIR case number(s) for your child(ren
b. If you entered your case number, click NEXT and it should take you to Section 4. An adult household member must sign. You do not have to list an SSN in Section 4.

2. BENEFITS

	Case Number
CalFresh
CalWORKs
FDPIR

If you are receiving CalFresh, California Work Opportunity and Responsibility to Kids (CalWORKs), or Food Distribution Program on Indian Reservations (FDPIR) benefits for your child, list the case number and do not complete Section 3. Go to Section 4.

Does your household receive any income?*

YesNo

List all household members including children enrolled for care. List total household gross income and how often it is received (e.g., weekly, every two weeks, twice a month, monthly, or annually.)

Applicants without income are requested to write a zero in the applicable field or mark no income. Any income field left blank is a positive indication of no income and certifies that there is no income to report. Applications with blank income fields will be processed as complete.

Notes:
a. Complete this section and sign the form in Section 4. Write the names of everyone in your household even if they do not have an income. Include yourself, your spouse, the child you are applying for, and all other household members. If your household includes any foster children formally placed by a state child welfare agency or a court, you may choose to include the child(ren) in this list.

b. Write the amount of income each person received last month before taxes or anything else was taken out and where it came from, such as earnings, pensions, and other income (see examples below for types of income to report If you have chosen to include any foster children in your care, only the personal use income is to be listed. Foster payments you receive from the placing agency for the care of the child do not need to be reported. Each income amount should be entered in the appropriate column on the form. If any amount last month was more or less than usual, write that person's usual monthly income.

C. If anyone is self-employed, write the amount of income that person earns from self-employment. Please call the number listed at the top of the form if you need help.

3. ALL OTHER HOUSEHOLDS*

	Names of all household members, including child(ren) listed above (Eg: Janet Smith)	Earnings from work before deductions (Eg: $200 / Weekly)	Child Support, Alimony (Eg: $150 / Twice a Month)	Payments from Pensions, Retirement, Social Security (Eg: $100/Monthly)	Earnings from any other income ($0)
1
2
3

INCOME TO REPORT

Earnings from Work
- Wages, salaries or tips
- Strike benefits
- Unemployment Compensation
- Worker's compensation
- Net income from self-employment
Child Support or Alimony
- Public assistance payments
- Alimony or child support payments
Pensions, Retirement, or Social Security
- Pensions
- Supplemental Security Income
- Retirement income
- Verteran's payments
- Social Security
Other Monthly Income
- Disability benefits
- Cash withdrawn from savings
- Interest Dividends
- Income from estates, trusts or investments
- Regular contributions from persons not living in the household
- Net royalties, annuities, or net rental income
- Military allowance for off-base housing
- Any other income

PENALTIES FOR MISREPRESENATION: I certify that all of the above informaiton is true and correct and that the CalFresh, CalWORKs, FDPIR, or other eligible program case number is current, correct, or that all income is reported. I understand that this information is being given for the receipt of Federal funds; that agency officials may verify the information on the meal benefit form (MBF) and that the deliberate misrepresentation of the information may subject me to prosecution under the applicable state and federal laws.

Notes:
a. The form must have a signature of an adult household member.

b. The adult household member who signs the statement must include the last four digits of his or her SSN. If they do not have an SSN, they will place a checkmark next to the No SSN line.

c. The last four digits of the adult household member's SSN is not needed if a CalFresh, CalWORKs, or FDPIR case number is provided.
4. Printed Name*
Parent / Guardian Email*
You will receive a copy of this PDF you just filled out thru this email address.
Last 4 of Social Security Number*
Date*

MonthDayYear
Date
Parent / Guardian Signature*

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PRIVACY ACT STATEMENT

The Richard B. Russel National School Lunch Act (NSLA) requires the information on this application. You do not have to give the information, but if you do not, we cannot approve the participant for free or reduced-price meals. You must include the last four digits of the SSN of the adult household member who signs the application. The last four digits of the SSN are not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP, or CalFresh), Temporary Assistance for Needy Families (TANF, or CalWORKs), Program or FDPIR case number for the participant or other (FDPIR) identifier or when you indicate that the adult household member signing the application does not have a SSN. We will use your information to determine if the participant is eligible for free or reduced-price meals, and for the administration and enforcement of the program.

The last four digits of the SSN may be used to identify the household member in verifying the correctness of the information stated on the form. This may include program reviews, audits, and investigations, and may include contacting employers to determine income, contacting a CalFresh, CalWORKs, or FDPIR office to determine current certification for CalFresh, CalWORKs, or FDPIR 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. The last four digits of the SSN may also be disclosed to programs as authorized under the NSLA and the Child Nutrition Act, the Comptroller General of the United States, and law enforcement officials for the purpose of investigating violations of certain federal, state, and local education, and health and nutrition programs.

5. RACIAL / ETHNIC IDENTITY

You are not required to answer these questions. If you choose to do so, please mark one or more of the following racial identities:
Race

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
Please mark one of the following ethnic identities:

Hispanic or LatinoNot Hispanic or Latino

FOR AGENCY USE ONLY

(SKIP THIS PAGE)

CATEGORICAL ELIGIBILITY
CalFresh/CalWORKs/FDPIR household categorically eligible?

YesNo
Foster child automatically eligible free?

YesNo
INCOME ELIGIBILITY

Annual Conversion (required if household reports various pay frequencies in Section 3): weekly times (x) 52, every 2 weeks X 26, twice a month X 24, monthly X 12 Total Household Income and Frequency: $ per Household Size
Total Household Income and Frequency
Per
Household Size
ELIGIBILITY CLASSIFICATION
Eligibility Classification

FreeReduced-priceBase
Determining Official Name
Determining Official Signature

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Date

MonthDayYear
Date

U.S. DEPARTMENT OF AGRICULTURE NONDISCRIMINATION 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 programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil 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.g., Braille, large print, audiotape, American Sign Language, etc, should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, 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 file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint filing cust.html and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call 866-632-9992. Submit your completed form or letter to USDA by:

1. Mail:

U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410

2. Fax: (202) 690-7442

3. Email: program.intake@usda.gov

This institution is an equal opportunity provider.
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