ࡱ> {~zc ~6bjbj 4ffp.  89tV(lj+>D$h'''''''$*x-'|||'+(|:+'|':)$,$ LU$ '&(0V(_$Rr.Fr.$$8r.$|||||||''H|||V(||||r.||||||||| : Income Eligibility Form Tier 1 Income Providers July 1, 2019-June 30, 2020 Dear Provider: This form must be completed and provided to your CACFP sponsor, along with proof of your household income, to determine your eligibility to receive the Tier I level of reimbursement for meals and snacks being served to the children in your care. The Welfare Reform Act of 1996 included a provision which allows Child Care Providers who participate in the Child and Adult Care Food Program, who themselves have low income households, to be eligible to claim meals served to children who live as members of the Providers household. If a Provider is determined eligible to receive the Tier I level of reimbursement for children enrolled in care due to household income being at or below the level of Reduced Price meals, that Provider is also eligible to receive the Tier I or Higher rate of reimbursement for those children who are members of the Providers household. To determine if you may qualify for this benefit, please complete the attached application form and return it to your CACFP Sponsor. Your sponsor will compare your monthly household income to the current income guidelines to determine if you qualify for the Tier I rate of reimbursement. By regulation, all listed incomes must be verified by your CACFP Sponsor. This means you must provide your sponsor with copies of several (not just one) recent paycheck stubs for anyone in the household who is employed, but not self-employed. If someone in the household receives benefits from Social Security, a pension or retirement, Unemployment Compensation, Life Insurance, or other such program you must supply a copy of the most recent granting letter from that source showing the amount to be received monthly. If benefits are being received from the Supplemental Nutrition Assistance Program (SNAP) (formerly known as Food Stamps), TANF, or the Food Distribution Program for Indian Reservations (FDPIR), you must supply a copy of the most recent granting letter showing the amount to be received, and the period of eligibility. You must also supply copies of checks to verify any other sources of income including Child Support or Alimony. All Child Care Providers are considered to be self-employed. For this reason, you must either supply current records of your business income and expenses to show your current net income from self-employment, or, if the net income from self-employment from the most recent year is representative of your current level of income, you may supply a copy of your most recent IRS 1040 form. Instructions: 1. Enter the name and age of a child for whom you may be making application. 2. Include the name of each person living in the Household. A Household is any group of persons who live together and share income and living expenses. These persons may or may not all be related to each other. 3. List the total income before deductions, from all sources, for all persons living in the household. 4. Include the last four (4) digits of the Social Security number of the household member or guardian who signs the application. If this person does not have a Social Security Number, the word NONE must be entered in the allotted space. 5. Include the signature, date of signature, address, and telephone number of the person completing the application. 6. Be sure to bring with you, or to send to your Sponsor, verification, as described above, for each source of household income. Return the completed form/documents to your sponsor. By regulation, if any of the above requested information is not provided with the application, your CACFP Sponsor may not determine you to be eligible to claim meals served to children who live as members of your household. Your Sponsor will also have to determine if you meet either the Tier I School or the Tier I Census requirements before you may be declared automatically eligible to receive the Tier I rate for any of the other children in your childcare. The following chart shows the upper income level for the Tier I category for the period July 1, 2019 to June 30, 2020. Eligibility Scale For Reduced-Price Meals Family SizeAnnualMonthlyTwice Per MonthEvery Two WeeksWeekly123,1071,926 963 889 445231,2842,6071,3041,204 602339,4613,2891,6451,518 759447,6383,9701,9851,833 917555,8154,6522,3262,1471,074663,9925,3332,6672,4621,231772,1696,0153,0082,7761,388880,3466,6963,3483,0911,546Each Additional Family Member8,177682341315158 If a member of your household becomes unemployed, you may become eligible for the above-described benefits during the period of unemployment, provided the loss of income causes the household income to fall within the eligibility guidelines. If a Foster Child is living as a member of your household, please indicate this on the application. 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  HYPERLINK "https://nam03.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.ocio.usda.gov%2Fsites%2Fdefault%2Ffiles%2Fdocs%2F2012%2FComplain_combined_6_8_12.pdf&data=02%7C01%7CPaula.Nadeau%40maine.gov%7C37538e69344f464cd0ed08d79066d3e2%7C413fa8ab207d4b629bcdea1a8f2f864e%7C0%7C0%7C637136643619496071&sdata=ULYop6GmbBiM89oXQayx%2BrJ2fdGHc5O5VmvA6kyoOAA%3D&reserved=0" USDA Program Discrimination Complaint Form, (AD-3027) found online at:  HYPERLINK "https://nam03.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.ascr.usda.gov%2Fcomplaint_filing_cust.html&data=02%7C01%7CPaula.Nadeau%40maine.gov%7C37538e69344f464cd0ed08d79066d3e2%7C413fa8ab207d4b629bcdea1a8f2f864e%7C0%7C0%7C637136643619506029&sdata=i%2Bcfze%2BRy6wmgD8g7f51pbmmqKZa57B%2Brefe2BX%2BIi8%3D&reserved=0" 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: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email:  HYPERLINK "mailto:program.intake@usda.gov" program.intake@usda.gov. This institution is an equal opportunity provider. Thank you. CACFP Staff APPLICATION FOR TIER 1- INCOME PROVIDERS CHILD AND ADULT CARE FOOD PROGRAM (CACFP) CHILD FOR WHOM APPLICATION IS BEING MADE: Name:_____________________ Age: ______ NOTE: If you are applying for CACFP benefits for a Foster Child, please check this box  FORMCHECKBOX  Foster Child. INSTRUCTIONS: (a) List the names of all persons living in your household. Be sure to include yourself and the child listed above. A Household is any group of persons who live together and share living expenses. These persons may or may not be related to each other. (b) Social Security Number Sections 9 and 17 of the National School Lunch Act require that the last four (4) digits of the Social Security Number of the adult household member or guardian who signs the application must be included in the allotted space. If that person does not have a Social Security number, that person must enter the word NONE in the allotted space. Provision of a Social Security number is not mandatory, but if the last four (4) digits of the Social Security Number is not given, or if the word NONE is not entered in the allotted space, the application cannot be approved. (c) Income: List ALL income from ALL sources received last month on the same line as the name of the person who received it. All income, except self-employment, must be GROSS, that is, it must be the amount received BEFORE DEDUCTIONS for taxes, Social Security, dues, insurances, etc. List each income amount under the correct column. As stated in the cover letter, all incomes must be verified by your CACFP sponsor, either through check stubs, copies of granting letters, copies of actual checks, or the most recent IRS-1040 forms. If you are now receiving SNAP, TANF or FDPIR benefits, and if the above named child is included in the grant, you may give your SNAP, TANF or FDPIR case number on the allotted line. DO NOT COMPLETE Part II, skip to Part III. Part III must include the printed name and signature of the adult who completed this application and the date the application was completed. If you are in the Military Privatized Housing Initiative or receive combat pay, please do not include these allowances as income. If you, or any other household member, receive SNAP, TANF or FDPIR benefits, please provide the case number below:  FORMCHECKBOX  SNAP case ID number: # _ _ _ _ _ _ _ _ _ (not EBT number)  FORMCHECKBOX  TANF case ID number: # _ _ _ _ _ _ _ _ _  FORMCHECKBOX  FDPIR case ID number: # _ _ _ _ _ _ _ _ _ LIST ALL HOUSEHOLD MEMBERS: Name of Household Member:Age:Monthly Gross Wages or Net Self-EmploymentMonthly TANF, Alimony, Welfare, Child SupportMonthly Pensions, SSI, Social Security, Workers Comp, Unemployment Comp, Insurance & Retirement:1. 2. 3. 4. 5. 6.  (Note: Weekly Income x 4.333 weeks; Bi-weekly Income x 2.15 weeks) Total Monthly Income: In accordance with Federal law and U.S. Department of Agriculture policy, this Day Care Home Sponsor 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 Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (866) 632-9992 (voice) or (800) 877-8339 (TTY)or (800)845-6136 (Spanish). USDA is an equal opportunity provider and employer. PENALTIES FOR MISREPRESENTATION: I certify that all of the above information is true and correct and that all household income is reported. I understand this information is being given in connection with the receipt of Federal Funds, which Program Officials must verify the information on the application and that deliberate misrepresentation of any of the information on this application may subject me to prosecution under applicable State and Federal Criminal Statutes. SIGNATURE: (Name of Adult)(Last 4 digits of SS#)(Signature of Adult)(Date) (Household Address of Adult)(Home Phone) (Work Phone)( I do not have a social security number THIS PORTION MUST BE COMPLETED BY THE DAY CARE HOME SPONSOR: Signature: _______________________________ Date: _____________ Is provider eligible for Tier I rate based on household income or direct certification? (circle one): Y N      (124LMN]^  T U    . 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