CHILD CARE FOOD PROGRAM FREE AND REDUCED-PRICE MEAL APPLICATION

(for Use by Sponsors of Unaffiliated Child Care Centers)

Primary Hours of Care


Please read the instructions and accompanying Parent Letter before completing this form. If you need assistance completing this form, call:

STEP 1: Complete the following table for all INFANTS and CHILDREN through age 18 that reside in the household, even if not related. (include child listed at top of form)
Child’s Name




Child’s Name




STEP 2: Do any household members (children or adults) receive Food Assistance Program (FAP/SNAP) or Temporary Assistance for Needy Families (TANF) benefits?


STEP 3: Household income and adult household member information (see reverse side for what types of income to report) (skip this step if you listed a case # in STEP 2)…
A. Children’s Income – sometimes children earn or receive income. Enter the total income received by all children listed in STEP 1, then check how often the income is received

Adult Household Member’s Name
Earnings from Work ($ Amount / How often?)*
Public Assistance/Child Support/Alimony ($ Amount / How often?)*
Pensions/Retirement/All Other Income ($ Amount / How often?)*
Last four digits of Social Security Number (SSN) of adult household member If no SSN, write “none.
STEP 4: Contact information and adult signature
By signing below, I am certifying (promising) that all information on this application is true and that all income is reported. I understand that this information is being given in connection with the receipt of federal funds and that institution officials may verify (check) the information. I am aware that if I purposely give false information, I may be prosecuted under applicable state and federal laws.
FOR CONTRACTOR USE ONLY
By signing below, I am certifying (promising) that all information on this application is true and that all income is reported. I understand that this information is being given in connection with the receipt of federal funds and that institution officials may verify (check) the information. I am aware that if I purposely give false information, I may be prosecuted under applicable state and federal laws



NOTE: If different income frequencies are listed, convert all income to an annual amount. Annual Income Conversion: Weekly x 52, Biweekly x 26, Twice a Month x 24, Monthly x 12


OPTIONAL: Child’s ethnic and racial identities………
We are required to ask for information about your child’s ethnicity and race. This information is important and helps to make sure that we are fully serving the community. Responding to this section is optional and does not affect your child’s eligibility for free or reduced-price meals.


INSTRUCTIONS for completing the Free and Reduced-Price Meal Application (use a pen and print all information other than signature)……

Print the name of the child you are applying for at the top pf the form. Print the name and address of the child care center the child attends, if not already pre-printed. Print the primary hours of care for your child. Circle the days of the week your child primarily attends the child care center and the meals that you expect your child to receive while in care: breakfast (BR), morning snack (MS), lunch (LU), afternoon snack (AS), supper (SU), and/or evening snack (ES)

IF ANY MEMBER OF YOUR HOUSEHOLD RECEIVES FOOD ASSISTANCE PROGRAM (FAP/SNAP) OR TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) BENEFITS, FOLLOW THESE

INSTRUCTIONS: STEP 1: List all children age 18 and under that are supported with the household’s income, even if they are not related to you. Be sure to include the child listed at the top of the form. If there is not enough space to list all children, use a second form and attach the forms together. List the date of birth of each child. In the next three columns, circle Yes or No to answer each question for each child listed

STEP 2: Enter either the FAP/SNAP or TANF case number in the designated space. The case number will be on your letter of eligibility; it is not the number on your EBT card

STEP 3: Skip this step.

STEP 4: Enter your address and phone # (if available). An adult household member must sign the form. Print the name of the person who signed the form, then enter the date signed.

IF YOU ARE APPLYING FOR A FOSTER CHILD, FOLLOW THESE INSTRUCTIONS: With appropriate documentation, foster children are automatically eligible for free meals regardless of the income of the household where they reside. You have the option to provide the child care center with official documentation from the foster care agency or court that placed the child in the household, rather than completing this application. Should you choose to complete this application, and you are applying only for a foster child(ren), then only complete STEPS 1 and 4. If you are applying for foster and non-foster children, complete STEPS 1, 3, and 4. If completing STEP 3, do not include payments to the household for the care of the foster child(ren). See the instructions listed below for the applicable steps.

ALL OTHER HOUSEHOLDS, FOLLOW THESE INSTRUCTIONS: STEP 1: List all children age 18 and under that are supported with the household’s income, even if they are not related to you. Be sure to include the child listed at the top of the form. If there is not enough space to list all children, use a second form and attach the forms together. List the date of birth of each child. In the next three columns, circle Yes or No to answer each question for each child listed.

STEP 2: Skip this step. S

STEP 3: A. Enter the total income received by all children listed in STEP 1, then check how often the income is received. B. List all adults age 19 and older that are supported with the household’s income, even if they are not related to you and even if they receive no income. If there is not enough space to list all adults, use a second form and attach the forms together. For each adult, list the amount of income he/she regularly receives before taxes or anything else is taken out and circle how often the income is received (frequency) in the appropriate columns. If self-employed, list net income. See examples below for sources of income to report. For any adult with no income, write “none” or “zero.” Any income fields that are blank will also be counted as a zero (0). Enter the total number of household members (all children and adults), then list the last four digits of the social security number (SSN) of the adult completing/signing the application (or write NONE if he/she has no SSN).

STEP 4: Enter your address and phone # (if available). An adult household member must sign the form. Print the name of the person who signed the form, then enter the date signed.

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