Utah CACFP Enrollment

Utah CACFP Enrollment Form/ Free and Reduced-Price Income Application

Complete one application per household. In order to count as enrollment record, Steps 1 & 4 must be completed.

Enrollment Date:

STEP 1

List ALL Household Members who are infants, children, and students up to and including grade 12 (if more spaces are required for additional names, attach another sheet of paper)

Definition of Household Member: “Anyone who is living with you and shares income and expenses, even if not related.” Children in State Foster care and children who meet the definition of Homeless, Migrant, Runaway or participate in Head start programs are eligible for free meals. Read How to Apply for Free and Reduced Price School Meals for more information

Child 1:

Child’s Name
Date of Birth

Normal Days and Hours in Care

Arrival Time
:
Departure Time
:
(Include ALL hours the child might be in care)
Child Type

Child 2:

Child’s Name
Date of Birth

Normal Days and Hours in Care

Arrival Time
:
Departure Time
:
(Include ALL hours the child might be in care)
Child Type

Child 3:

Child’s Name
Date of Birth

Normal Days and Hours in Care

Arrival Time
:
Departure Time
:
(Include ALL hours the child might be in care)
Child Type

Child 4:

Child’s Name
Date of Birth

Normal Days and Hours in Care

Arrival Time
:
Departure Time
:
(Include ALL hours the child might be in care)
Child Type

Child 5:

Child’s Name
Date of Birth

Normal Days and Hours in Care

Arrival Time
:
Departure Time
:
(Include ALL hours the child might be in care)
Child Type

STEP 2

Do any of the Household Members (including you) currently participate in one or more of the following eligible assistance programs?:

If NO > Go to STEP 3
A. This box indicates which program applicant is enrolled in.
B. Do any Household Members currently participate in one of the following eligible assistance programs? (circle only one)

STEP 3:

Report Income for ALL Household Members (Skip this step if you answered ‘YES’ to STEP 2)

A. Child Income

Sometimes children in the household earn or receive income. Please include the TOTAL income received by all Household Members listed in STEP 1 here.

$
List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do not receive income, report total gross income(before taxes) for each source in whole dollars (no cents) only. If they do not receive income from any source, write “0” or leave any fields blank, you are certifying (promising) that there is no income to report

Members 1

Name of Adult Household Members
How often?
Earnings from Work
How often?
Public Assistance/ Child Support/Alimony
How often?
Pensions/ Retirement. Other income

Members 2

Name of Adult Household Members
How often?
Earnings from Work
How often?
Public Assistance/ Child Support/Alimony
How often?
Pensions/ Retirement. Other income

Members 3

Name of Adult Household Members
How often?
Earnings from Work
How often?
Public Assistance/ Child Support/Alimony
How often?
Pensions/ Retirement. Other income

Members 3

Name of Adult Household Members
How often?
Earnings from Work
How often?
Public Assistance/ Child Support/Alimony
How often?
Pensions/ Retirement. Other income

Check if no SSN

STEP 4:

Contact information and adult signature
Consent
Address
Printed name of adult signing the form
MM slash DD slash YYYY

INSTRUCTIONS

Sources of Income

Sources of income for Children

Example(s)
  • A child has a regular full or part-time job where they earn a salary or wages
  • A child is blind or disabled and receives Social Security benefits
  • A Parent is disabled, retired, or deceased, and their child receives Social Security benefits
  • A friend or extended family member regularly gives a child spending money
  • A child receives regular income from a private pension fund, annuity, or trust
Sources of income for Children

Sources of Income for Adults

Earnings from Work
If you are in the U.S. Military:
Basicpayandcashbonuses (do NOT include combat pay, FSSA or privatized housing allowances)
Public Assistance/ Alimony/ Child Support
Pensions/ Retirement/ All other Income

OPTIONAL

Children’s Racial and Ethnic identities

We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children’s eligibility for free or reduced price meals
Ethnicity (check one):
Race (check one or more):
The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF-FEP) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.

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:

mail:

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

fax: (202) 690-7442; or

email: program.intake@usda.gov.

This institution is an equal opportunity provider.

Do not fill out

For Official Use Only

Annual Income Conversion: Weekly x 52, Every 2 weeks x 26, Twice a month x 24, Monthly x 12
Income
Categorical Eligibility
Categorical Eligibility
MM slash DD slash YYYY
Determining Official’s Signature

MM slash DD slash YYYY
Confirming Official’s Signature

MM slash DD slash YYYY
Verifying Official’s Signature