Report: Child Enrollment

CHILDCAREFOODPROGRAMFREEANDREDUCED-PRICEMEALAPPLICATION

Child’sName: CenterName&Address:

AnnieSmith Danielle'sDemoSponsoredCenterFL

PleasereadtheinstructionsandaccompanyingParentLetterbeforecompletingthisform.Ifyouneedassistancecompletingthisform,call:

STEP1:CompletethefollowingtableforallINFANTSandCHILDRENthroughage18thatresideinthehousehold,evenifnotrelated.(includechildlistedattopofform)……….… Child’sName(LastName,FirstName)

STEP2:Doanyhouseholdmembers(childrenoradults)receiveFoodAssistanceProgram(FAP/SNAP)orTemporaryAssistanceforNeedyFamilies(TANF)benefits?

IfNO,gotoSTEP3.IfYES,enteroneofthefollowingcasenumbers,thengotoSTEP5

FAP/SNAPCaseNumber: orTANFCaseNumber:

STEP3:Children’sIncomeInformation(seereversesideforwhattypesofincometoreport)(skipthisstepifyoulistedacase#inSTEP2)

Children’sIncome-sometimeschildrenearnorreceiveincome.EnterthetotalincomereceivedbyallchildrenlistedinSTEP1,thencheckhowoftentheincomeisreceived.

Children’sincome-Total:$

STEP4:Householdincomeandadulthouseholdmemberinformation(seereversesideforwhattypesofincometoreport)(skipthisstepifyoulistedacase#inSTEP2)

AdultHouseholdMembersandIncome-listalladulthouseholdmembers(age19andup)eveniftheydonotreceiveincome.Foreachadult,listthetotalgrossincome(beforetaxes &deductions)fromeachsourceinwholedollarsonly(nocents)andhowoftenitisreceived(i.e.,weekly,bi-weekly,twiceamonth,monthly,orannually).Foranadultthat doesnotreceiveincomefromanysource,write“none”or“0.”Ifyouenter“none”or“0”orleaveanyincomefieldsblank,youarecertifyingthatthereisnoincometoreport.

TotalHouseholdMembers(AddSTEP1&4): LastfourdigitsofSocialSecurityNumber(SSN)ofadulthouseholdmember: IfnoSSN,write“none.”

STEP5:Contactinformationandadultsignature……………………………………………………………………………………………………………………………………………….………

Bysigningbelow,Iamcertifying(promising)thatallinformationonthisapplicationistrueandthatallincomeisreported.Iunderstandthatthisinformationisbeinggiveninconnectionwiththereceipt offederalfundsandthatinstitutionofficialsmayverify(check)theinformation.IamawarethatifIpurposelygivefalseinformation,Imaybeprosecutedunderapplicablestateandfederallaws.

400W.9thStreetAPT.1504 Cincinnati TX45203

Homeaddress(ifavailable): Daytimephone#:

StreetAddress,City,State,ZipCode

Signatureofadulthouseholdmember:

Printedname:

Datesigned:

OPTIONAL:Child’sethnicandracialidentities Wearerequiredtoaskforinformationaboutyourchild’sethnicityandrace.Thisinformationisimportantandhelpsmakesurethatwearefullyservingthecommunity. Respondingtothissectionisoptionalanddoesnotaffectyourchild’seligibilityforfreeorreduced-pricemeals. Ethnicity(checkone): HispanicorLatino NotHispanicorLatino X

Race(checkoneormore): AmericanIndianorAlaskanNative AsianBlackorAfricanAmericanNativeHawaiianorOtherPacific WhiteX

FORCONTRACTORUSEONLY:

CategoricalEligibility:FAP/SNAPorTANFHouseholdFosterChild TotalHouseholdSize: TotalHouseholdIncome:$

EligibilityDetermination:FreeReduced-PriceNon-needy HowOftenIncomeisReceived(Frequency): BiweeklyTwiceaMonthMonthlyAnnually Weekly

NOTE:Ifdifferentincomefrequenciesarelisted,convertallincometoanannualamount.AnnualIncomeConversion:Weeklyx52,Biweeklyx26,TwiceaMonthx24,Monthlyx12

ReasonforNon-needyStatus

DateofBirthAttendsthiscenter?(circle)FosterChild?(circle)Migrant?(circle)Homeless/Runaway?(circle) No YesNo YesNo YesNo Yes Smith,Annie 09/04/2017 YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo

Howoftenreceived?(checkonlyone):WeeklyBi-WeeklyTwiceaMonthMonthlyAnnually

AdultHouseholdMember’sName (LastName,FirstName) EarningsfromWork ($Amount/Howoften?) PublicAssistance/ChildSupport/Alimony ($Amount/Howoften?) Pensions/Retirement/AllOtherIncome ($Amount/Howoften?) Moore,Jayda $ /WeeklyBiweeklyMonthly $ WeeklyBiweeklyMonthly/ $ WeeklyBiweeklyMonthly/ TwiceaMonthAnnualy TwiceaMonthAnnualy TwiceaMonthAnnualy $ WeeklyBiweeklyMonthly/ $ WeeklyBiweeklyMonthly/ $ WeeklyBiweeklyMonthly/ TwiceaMonthAnnualy TwiceaMonthAnnualy TwiceaMonthAnnualy $ WeeklyBiweeklyMonthly/ $ WeeklyBiweeklyMonthly/ $ WeeklyBiweeklyMonthly/ TwiceaMonthAnnualy TwiceaMonthAnnualy TwiceaMonthAnnualy

………………………………………………………………………………………………………………………………

IncometooHighIncompleteApplicationOtherReason: Date: DeterminingOfficial’sSignature: SecondPartyCheckSignature Date: Jayda,Moore (513)365-6948

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INSTRUCTIONSforcompletingtheFreeandReduced-PriceMealApplication(useapenandprintallinformationotherthansignature)

IFANYMEMBEROFYOURHOUSEHOLDRECEIVESFOODASSISTANCEPROGRAM(FAP/SNAP)ORTEMPORARYASSISTANCEFORNEEDYFAMILIES(TANF)BENEFITS, FOLLOWTHESEINSTRUCTIONS:STEP1:Listallchildrenage18andunderthataresupportedwiththehousehold’sincome,eveniftheyarenotrelatedtoyou.Besuretoincludethe childlistedatthetopoftheform.Ifthereisnotenoughspacetolistallchildren,useasecondformandattachtheformstogether.Listthedateofbirthofeachchild.Inthenextthreecolumns,circleYesor Notoanswereachquestionforeachchildlisted.STEP2:EntereithertheFAP/SNAPorTANFcasenumberinthedesignatedspace.Thecasenumberwillbeonyourletterofeligibility;itisnotthenumberon yourEBTcardSTEP3:Skipthisstep.STEP4:Skipthisstep.STEP5:Enteryouraddressandphone#(ifavailable).Anadulthouseholdmembermustsigntheform.Printthenameofthepersonwhosigned theform,thenenterthedatesigned.

IFYOUAREAPPLYINGFORAFOSTERCHILD,FOLLOWTHESEINSTRUCTIONS:Withappropriatedocumentation,fosterchildrenareautomaticallyeligibleforfreemealsregardless oftheincomeofthehouseholdwheretheyreside.Youhavetheoptiontoprovidethechildcarecenterwithofficialdocumentationfromthefostercareagencyorcourtthatplacedthechildinthehousehold, ratherthancompletingthisapplication.Shouldyouchoosetocompletethisapplication,andyouareapplyingonlyforafosterchild(ren),thenonlycompleteSTEPS1and5.Ifyouareapplyingforfoster andnon-fosterchildren,completeSTEPS1,3,4and5.IfcompletingSTEP3,donotincludepaymentstothehouseholdforthecareofthefosterchild(ren).Seetheinstructionslistedbelowforthe applicablesteps.

ALLOTHERHOUSEHOLDS,FOLLOWTHESEINSTRUCTIONS:STEP1:Listallchildrenage18andunderthataresupportedwiththehousehold’sincome,eveniftheyarenotrelatedtoyou.Besureto includethechildlistedatthetopoftheform.Ifthereisnotenoughspacetolistallchildren,useasecondformandattachtheformstogether.Listthedateofbirthofeachchild.Inthenextthreecolumns, circleYesorNotoanswereachquestionforeachchildlistedSTEP2:Skipthisstep.STEP3:EnterthetotalincomereceivedbyallchildrenlistedinSTEP1,thencheckhowoftentheincomeisreceived. STEP4:Listalladultsage19andolderthataresupportedwiththehousehold’sincome,eveniftheyarenotrelatedtoyouandeveniftheyreceivenoincome.Ifthereisnotenoughspacetolistalladults, useasecondformandattachtheformstogether.Foreachadult,listtheamountofincomehe/sheregularlyreceivesbeforetaxesoranythingelseistakenoutandcirclehowoftentheincomeisreceived (frequency)intheappropriatecolumns.Ifself-employed,listnetincome.Seeexamplesbelowforsourcesofincometoreport.Foranyadultwithnoincome,write“none”or“0.”Anyincomefieldsthatare blankwillalsobecountedasazero(0).Enterthetotalnumberofhouseholdmembers(allchildrenandadults),thenlistthelastfourdigitsofthesocialsecuritynumber(SSN)oftheadultcompleting/signing theapplication(orwriteNONEifhe/shehasnoSSN).STEP5:Enteryouraddressandphone#(ifavailable).Anadulthouseholdmembermustsigntheform.Printthenameofthepersonwhosignedthe form,thenenterthedatesigned.

Earningsfromwork

SocialSecurity

•DisabilityPayments

•Survivor’sBenefits

Incomefromperson outsidethehousehold

Incomefromany othersource

SourcesofIncomeforChildren

Achildhasaregularfullorpart-timejob wheretheyearnasalaryorwages

•Achildisblindordisabledandreceives SocialSecuritybenefits

•AParentisdisabled,retired,ordeceased, andtheirchildreceivesSocialSecurity

Afriendorextendedfamilymemberregularly givesachildspendingmoney

Achildreceivesregularincomefromaprivate pensionfund,annuity,ortrust

EarningsfromWork

•Salary,wages,cashbonuses

•Netincomefromselfemployment (farmorbusiness)

IfyouareintheU.S.Military:

•Basicpayandcashbonuses(do NOTincludecombatpay,FSSAor privatizedhousingallowances)

•Allowancesforoff-basehousing, foodandclothing

SourcesofIncomeforAdults

•Unemploymentbenefits

•Worker’scompensation

•SupplementalSecurity Income(SSI)

•Cashassistancefrom Stateorlocalgovernment

•Alimonypayments

•Childsupportpayments

•Veteran’sbenefits

•Strikebenefits

Pensions/Retirement/AllOtherIncome

•SocialSecurity(includingrailroad retirementandblacklungbenefits)

•Privatepensionsordisability benefits

•Regularincomefromtrustsorestates

•Annuities

•Investmentincome

•Earnedinterest

•Rentalincome

•Regularcashpaymentsfromoutside household

TheRichardB.RussellNationalSchoolLunchActrequiresthat,unlessyoulistacurrentFoodAssistanceProgram(FAP/SNAP)orTemporaryAssistanceforNeedyFamilies(TANF)casenumberorareapplyingfor afosterchild,youmustincludethelastfourdigitsoftheSocialSecurityNumber(SSN)oftheadulthouseholdmembersigningtheapplicationorindicatethatthesignerdoesnothaveaSSN.Providingthelast fourdigitsofaSSNisnotmandatory,butifthisinformationisnotgivenoranindicationisnotmadethatthesignerdoesnothaveaSSN,theapplicationcannotbeapproved.Theinformationprovidedonthis formmaybeverifiedthroughprogramreviews,audits,andinvestigationsandmayincludecontactingemployerstodetermineincome,contactingawelfareofficetoverifyreceiptofFAP/SNAPorTANFbenefits, contactingthestateemploymentsecurityofficetodeterminetheamountofbenefitsreceived,andcheckinganydocumentationproducedbythehouseholdtoprovetheamountofincomereceived.These verificationeffortsmayresultinalossorreductionofbenefits,administrativeclaims,orlegalactionsifincorrectinformationisreported.Wemayshareyoureligibilityinformationwitheducation,health,and nutritionprogramstohelpthemevaluate,fund,ordeterminebenefitsfortheirprograms;auditorsforprogramreviews;andlawenforcementofficialstohelptheminvestigateviolationsofprogramrules.

Thisinstitutionisanequalopportunityprovider.PleaserefertotheaccompanyingParentLettertoreadthefullNondiscriminationStatement

PublicAssistance/ Alimony/ChildSupport

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NameofChild:AnnieSmith

DearParent:

NameofFacility:

Danielle'sDemoSponsoredCenter

PleasefilloutthefollowinginformationsothatyourchildmayparticipateintheChildCareFoodProgram,whichreimburses childcareprovidersforservingnutritious,well-balancedmealstochildreninchildcare.

Checkhereandsign/datebelowifyourchilddoesnotreceivemealswhileincare

XCheckhereandsign/datebelowifyourchildhasnoregularlyscheduledhoursofcare

FloridaDepartmentofHealth

ChildCareFoodProgram ChildParticipationForm

a.m. a.m. p.m.to p.m. a.m. a.m. p.m.to p.m. a.m. a.m. p.m.to p.m. a.m. a.m. p.m.to p.m. a.m. a.m. p.m.to p.m. a.m. a.m. p.m.to p.m. OR PMSnack Breakfast AMSnack Supper EveSnack Lunch PMSnack Breakfast AMSnack Supper EveSnack Lunch PMSnack Breakfast AMSnack Supper EveSnack Lunch PMSnack Breakfast AMSnack Supper EveSnack Lunch PMSnack Breakfast AMSnack Supper EveSnack Lunch PMSnack Breakfast AMSnack Supper EveSnack Lunch a.m. a.m. p.m.to p.m.PMSnack Breakfast AMSnack Supper EveSnack Lunch Sunday Saturday Friday Thursday Wednesday Tuesday Monday

Ifchildcarehoursarenotthesameeveryday,pleasecompletethischart.

PhoneNumber: PrintedName: Date: SignatureofParent/Guardian: MooreJayda (513)365-6948 5:00 6:00 a.m. p.m. p.m. a.m. X X X X to NormalHoursinCare MealsNormallyReceivedWhileinCare EveSnack Lunch Supper AMSnack PMSnack Mon-Fri Day Breakfast Ifchildcarehoursarethesameeveryday,pleasecompletethischart.

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