INCOME ELIGIBILITY GUIDELINES Every 2 Household Size Annually Monthly a month Weekly Weeks $22,459 $1,872 $864 $432 1 $936 $30,451 $2,538 $1,172 $586 2 $1,269 $38,443 $3,204 $1,479 $740 3 $1,602 $46,435 $3,870 $1,786 $893 4 $1,935 $54,427 $4,536 $2,094 $1,047 5 $2,268 $62,419 $5,202 $2,401 $1,201 6 $2,601 $70,411 $5,868 $2,709 $1,355 7 $2,934 $78,403 $6,534 $3,016 $1,508 8 $3,267 For each additional $7,992 $666 $308 $333 $154 family member, add Attachment H3 FAMILY INCOME STATEMENT INSTRUCTIONS Please complete the Child and Adult Care Food Program Family Income Statement using the instructions below. Sign the statement and return it to the sponsor. Call the sponsor if you need help: #____________________ PART 1 - PARTICIPANT'S INFORMATION: COMPLETE THIS PART. (1) the name(s) of your own child(ren) enrolled in the day care home. Mark the box if the child is a foster child in your care. PART 2A - HOUSEHOLDS GETTING OTHER PROGRAM BENEFITS: SNAP (formerly known as Food Stamps)/ Food Distribution Program on Indian Reservations (FDPIR) / Temporary Assistance for Needy Families (TANF) / National School Lunch Program (NSLP) / Low Income Families (LIF) / Medicaid (except for long term care) / Low Income Energy Assistance / Child Care Assistance (except for Advanced Special Need) / and/or Women, Infants And Children (WIC)) COMPLETE THIS PART AND PART 3. (1) List current SNAP case number or TANF or FDPIR or other categorically eligible program identification number. Do not complete Part 2B. (2) An adult household member must sign the statement in PART 3. PART 2B - ALL HOUSEHOLDS: COMPLETE THIS PART AND PART 3. (1) the names of everyone in your household.
INCOME ELIGIBILITY GUIDELINES Household Size Annually Monthly Every 2 Weeks a month Weekly 1 $22,459 $1,872 $864 $936 $432 2 $30,451 $2,538 $1,172 $1,269 $586 3 $38,443 $3,204 $1,479 $1,602 $740 4 $46,435 $3,870 $1,786 $1,935 $893 5 $54,427 $4,536 $2,094 $2,268 $1,047 6 $62,419 $5,202 $2,401 $2,601 $1,201 7 $70,411 $5,868 $2,709 $2,934 $1,355 8 $78,403 $6,534 $3,016 $3,267 $1,508 For each additional family member, add $7,992 $666 $308 $333 $154 Attachment H3 FAMILY INCOME STATEMENT INSTRUCTIONS Please complete the Child and Adult Care Food Program Family Income Statement using the instructions below. Sign the statement and return it to the sponsor. Call the sponsor if you need help: #____________________ PART 1 - PARTICIPANT'S INFORMATION: COMPLETE THIS PART. (1) the name(s) of your own child(ren) enrolled in the day care home. Mark the box if the child is a foster child in your care. PART 2A - HOUSEHOLDS GETTING OTHER PROGRAM BENEFITS: SNAP (formerly known as Food Stamps)/ Food Distribution Program on Indian Reservations (FDPIR) / Temporary Assistance for Needy Families (TANF) / National School Lunch Program (NSLP) / Low Income Families (LIF) / Medicaid (except for long term care) / Low Income Energy Assistance / Child Care Assistance (except for Advanced Special Need) / and/or Women, Infants And Children (WIC)) COMPLETE THIS PART AND PART 3. (1) List current SNAP case number or TANF or FDPIR or other categorically eligible program identification number. Do not complete Part 2B. (2) An adult household member must sign the statement in PART 3. PART 2B - ALL HOUSEHOLDS: COMPLETE THIS PART AND PART 3. (1) the names of everyone in your household.
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