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Return this completed form to: The Children's Center

Household Income Eligibility Statement

Part 1 – Foster Child - Complete Parts 1 and 4 (Complete one form for each foster child. A foster child is a child who is living with a household but remains the legal responsibility of the welfare agency or court. A foster child is considered a household of one.)

Name of Foster Child Age Birth Date

Child’s personal use income per month $ If none available, list $ 0.

Part 2 – Households Receiving Food Stamp, FIP or FDPIR Benefits Complete Parts 2 and 4

Full Names of Children Enrolled for Child Care	Age	Birth Date	Food Stamp Benefit Case Number	FIP Benefit Case Number	FDPIR Benefit Case Number

Part 3 – Households NOT Receiving Food Stamp, FIP or FDPIR Benefits Complete Parts 3 and 4

First and Last Names of All Household Members	Enrolled for Child Care (✓)	Age	Child’s Birth Date	Monthly Earnings from work (before deductions)	Monthly Welfare, Child Support, or Alimony	All Other Income (Indicate source and amount)	Check if No Income (✓)

Part 4 – All Households

I certify that the information provided on this form is true and correct. I understand that: this institution will receive federal funds based on the information I provide; that program officials may verify the information, and that I may be prosecuted if I purposely give false information.

Signature of Adult Household Member Date Social Security Number

Privacy Act Information: Social Security Numbers

Section 9 of the National School Lunch Act requires that, unless your child’s Food Stamp/FIP/FDPIR case number is provided, you must include the social security number of the adult household member signing this Statement or indicate that the household member does not have a social security number. Provision of a social security number is not mandatory, but if a social security number is not given or an indication is not made that the signer does not have such a number, the Statement cannot be approved. The social security number may be used to identify the household member in carrying out efforts to verify the correctness of information stated on the Statement.

	For Institution Use Only
Total Household Members:	Total Monthly Income: $		Approved Category: A B C
Institution Official Signature:		Approval Date:

This form is valid for 12 months from the date of institution signature. Approval date and signature are required.

In accordance with Federal law and U. S. Department of Agriculture (USDA) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D. C. 20250-9410 or call (800) 795-3272 or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.

Revised 6/08