INCOME ELIGIBILITY STATEMENTS

Income Eligibility Statements

What?• CACFP enrollment form• Income Eligibility Statement used to determine reimbursement category

When?• When a participant first enrolls at your center • At least once annually for every participant – IES is valid for 1 year

Why?• Federal CACFP regulation 226.15(e)(2) requires it• All participants must be formally enrolled • Correct reimbursement category needed for the MEL and the claim

Income Eligibility StatementIt’s Two Forms in One

Top Portion:Enrollment Form

Bottom Portion:Income

Eligibility Statement

IES: Part Two and Three- Income Eligibility Information

PART TWO: TANF and/or SNAP RECIPIENTS If anyone in the household is a TANF or SNAP recipient:

– Circle the benefit (TANF and/or SNAP).– Enter only the TANF and/or SNAP case number. Do not enter a SSN or any other number in this box;

these other numbers are UNACCEPTABLE and will cause a delay in processing this form.

PART THREE: ENROLLED IN HEAD START If the child is enrolled in Head Start, please indicate the child’s name in this section.

IES: Part Four Foster Child

IES: Part Five- Total Household Income

PART FIVE: TOTAL HOUSEHOLD INCOME

IES: Part Six- Certification, Signature, and Social Security Number (Last Four Digits)

PART SIX: PARENT SIGNATURE & CERTIFICATION

IES: Back of Form

PART SEVEN: CIVIL RIGHTS INFORMATION This section does not have to be completed

to receive meal benefits But, it is important that this section is filled

out to determine that everyone is receiving benefits on a fair basis and not being discriminated against

CENTER USE ONLY: IES CLASSIFICATION The determining official must check the front

and back of the IES to ensure all sections are complete.

The form must be classified, signed, and dated by the determining official.

Please have an another staff member to verify that the IES is completed and classified correctly.

Parent Letter to Household

QUESTIONS