Official Use Only: Annual Income Conversion: Weekly x 52, Every 2 weeks x 26, Twice a month x 24, Monthly x 12
The participant in the day care facility may qualify for free or reduced price meals if your household
income falls within the limits on this chart.
Privacy Act Statement: 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 social security of the adult household
member who signs the application. The social security number is not required when you apply on behalf
of a foster child or you list a Food Stamp, Temporary Assistance for Needy Families (TANF) Program or
Food Distribution Program on Indian Reservations (FDPIR) case number for your child or other (FDPIR)
identifier 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 Program.
Non-discrimination Statement: 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.
Households that receive Food Stamps, TANF, FDPIR, SSI or Medicaid: Complete the following:
Part I: For family day care home and child care center, list participant’s name and a Food Stamp, TANF, or FDPIR case
number. For adult day care, list participant’s name and a Food Stamp, TANF, FDPIR, SSI or Medicaid case number.
Note: foster children (children placed in the household by the court system) can be included in this section. A
separate form is no longer needed for foster children.
Part II: Skip this part.
Part III: Child care centers only. Provide the normal days and hours your child is in attendance in the center and indicate
the meals he/she normally receives while in care.
Part IV: Sign the form. A Social Security Number is not necessary.
Part V: Answer this question if you choose to.
All other Households, including WIC households, complete the following:
Part I: For family day care home, child care center or adult day care, list participant’s name.
Part II: To report total household income from last month, complete the following:
Column A-Name: List the first and last name of each person living in your household as an economic unit. You must
indicate yourself and all children living with you (including foster and non-foster children). In the case of an adult
participant, the adult participant, and if residing with the adult participant, the spouse and dependent(s) of the adult
participant. Attach another sheet if necessary.
Column B-Gross Income last month and how often it was received: Next to each person’s name, list each type of
income received last month, and how often it was received.
Box 1: List the gross income each person earned from work. This is not the same as take-home pay. Gross income is the
amount earned before taxes and other deductions. The amount should be listed on your pay stub, or your boss can tell you.
Next to the amount, write how often the person got it (weekly, every other week, twice a month, or monthly).
Box 2: List the amount each person got last month from welfare, child support, alimony.
Box 3: List Social Security, pensions, and retirement.
Box 4: List all other income sources including Worker’s Compensation, unemployment, strike benefits, Supplemental
Security Income (SSI), Veteran’s benefits IVA benefits), disability benefits, regular contributions from people who do not
live in your household. Report net income from self-owned businesses, farming, or rental income. Next to the amount,
write how often the person got it. If you are in the Military Housing Privatization Initiative do not include this housing
allowance.
Column C-Check if no income: If the person does not have any income, check the box.
Part III: Child care centers only. Provide the normal days and hours your child is in attendance in the center and indicate
the meals he/she normally receives while in care.
Part IV: An adult household member must sign the form, and list the last four digits of his/her social security number.
Or, mark the box if he/she does not have one.
Part V: Answer this question if you choose to.
Privacy Act Statement: This explains how we use the information you give us.
The United States Department of Agriculture (USDA) issued revised Income Eligibility
Statements (IES) and other required forms to all state agencies to disseminate to institutions
participating in the Child and Adult Care Food Program (CACFP). The newly revised IES package
includes the following: IES form and instructions, reduced income guidelines template with
privacy and non-discrimination statement, Sharing Information with Medicaid/SCHIP letter,
sample house-hold letters based on program type, and template letters to use when verifying
income and reporting the results of the verification.
The revised IES package and supporting documents is available at
http://www.decal.ga.gov/BftS/FormList.aspx?cat=CACFP.
Q. What information do I issue to parents?
A. Institutions and facilities should issue the IES form, reduced income guidelines with the
privacy and non-discrimination statement, appropriate household letter, and the Sharing
Information with Medicaid/SCHIP letter to parents/guardians of children/adults participating in
the CACFP.
Q. Can centers/day care homes require parents/guardians to complete the IES form as part of
the enrollment package?
A. Centers/day care homes can request that parents/guardians complete the form as part of
the enrollment process, but centers should not require parents/guardians to complete the
form nor should they have policies/practices in place that negatively impacts the
prospective/current participant’s enrollment if the parent declines or fails to complete or
submit the form. This action would be in violation of the Program.
Q. Why is it necessary to issue the Sharing Information with Medicaid/SCHIP letter to
parents?
A. Parents/guardians that do not wish to have their information shared with either Medicaid or
SCHIP must complete the form and return to facility. Otherwise and when requested by Bright
from the Start or the United States Department of Agriculture (USDA), parent/guardian
information will be shared with Medicaid/SCHIP.
Q. Is it necessary to have three official’s signatures on the new IES form-especially when the
center is an independent center with only one staff person managing the CACFP?
A. No. Only one signature is required for Independent centers with only one staff person
responsible for managing the CACFP. However, institutions with more than one person
managing the CACFP, and center and administrative sponsors are required to have a minimum
of two signatures: determining official and confirming official.
Q. What is the purpose of having a determining and confirming official signature?
A. The confirming official will review the form and ensure accuracy and completeness. IES
forms are considered current and valid until the last day of the month in which the form was
dated on year earlier. The date to be used to make this determination is the date in which the
sponsor or institution official signs the IES form to certify eligibility of the participant.
Q. How long is the IES form considered current and valid?
A. IES forms are considered current and valid until the last day of the month in which the form
was dated one year previously. The date used to make this determination is the date in which
the sponsor/ independent center official or parent/guardian signs the IES form. CACFP
institutions and SFSP sponsors must decide which date they will use as the effective date and
apply this date to all income eligibility forms submitted on behalf of all participants. CACFP
institutions and SFSP sponsors are required to complete the Income Eligibility - Effective Date
Option Form. In addition, institutions must indicate the options chosen in Section VIII.
Recordkeeping (Item #2) of their Management Plan.
This means that sponsor and independent center officials should not request parent/guardians
to complete IES forms at a specific frequency (e.g. start of each school year, every June, etc.).
Request made by the sponsor or independent center official for IES form completion should be
based solely on the expiration date of the IES forms.
Q. Do I send a report to Bright from the Start listing parent/guardians that want their
information shared with Medicaid/SCHIP?
A. No. When instructed by USDA, Bright from the Start will request and collect data from
institutions.
Q. Can this form be used for children in childcare facilities and adults in adult daycare
facilities?
A. Yes.
Q. Can siblings be listed on one form?
A. Yes. Siblings from the same household can be listed on one form as long as there is space
available.
Q. When do I verify parent/guardian income?
A. At the request of the United States Department of Agriculture (USDA), Bright from the Start,
or any of its agents.
Q. Where can I get copies of the IES form and supporting documents?
A. Access Bright from the Start’s webpage at
http://www.decal.ga.gov/BftS/FormList.aspx?cat=CACFP
Q. Can I still participate in the CACFP if parents do not complete the IES form or do not return
the form to my center?
A. Yes. However, children that do not have IES forms on file must be placed in the “paid”
category on the roster, which will effect monthly reimbursement. Centers that are using the IES
form to capture annual enrollment information will be required to use an alternate enrollment
form that captures at a minimum the name of the child, normal hours and days of care and
meals the child usually receives while in attendance.
Q. What if the form is completed by the parent but is not signed and dated by the sponsor or
independent official. Is the form valid?
A. The form would neither be current nor valid for free or reduced price meals since the
signature and date of the sponsor or independent official is the certification of the eligibility of
the participant.
Q. Are households required to report changes in circumstances?
A. No, Public Law 108-265 modified the requirements related to reporting changes in income
during the period of eligibility covered by the application. Households are not required to
report changes in circumstances, such as increase in income, a decrease in household size, or
when the household is no longer certified eligible for benefits through Supplemental Nutrition
Assistance Programs (SNAP) or Temporary Assistance for Needy Families (TANF).
Q. Are temporary approvals (45 days) still required when no income is reported?
A. No. Temporary approvals previously provided for short term assistance, such as when a
household experienced a temporary income reduction or when no income was reported have
been eliminated, are no longer required. Now, year-long eligibility includes households that
report no income on their IES forms.
Q. Can parents list some but not all of the household income received?
A. No, the IES form requests all the household income including the frequency. By signing the
IES form the parent/guardian certifies that all the information on the form is true and that all
income is reported and that they understand that the center or day care home will receive
Federal funds based on the information listed by the parent/guardian.
Dear Parent/Guardian:
If your children qualify for free or reduced price meals, they may also be able to get free or low cost
health insurance through Medicaid or the State Children's Health Insurance Program (SCHIP).
Children with health insurance are more likely to get regular health care and are less likely to
become sick.
Because health insurance is so important to children's well-being, the law allows us to tell Medicaid
and SCHIP that your children are eligible for free or reduced price meals, unless you tell us not
to. Medicaid and SCHIP only use the information to identify children who may be eligible for their
programs. Program officials may contact you to offer to enroll your children in this health insurance
program. Filling out the CACFP Meal Benefit Income Eligibility Forms does not automatically enroll
your children in health insurance.
If you do not want us to share your information with Medicaid or SCHIP, fill out the form below and
send it with your Income Eligibility Form to [address] by [date]. (Sending in this form will not change
whether your children get free or reduced price meals.).
No! I DO NOT want information from my CACFP Meal Benefit Income Eligibility Form
shared with Medicaid or the State Children's Health Insurance Program.
If you checked no, fill out the form below.