Document Sample
					                             ADULT DAY CARE COMPONENT

Please complete the Application for Free and Reduced-Price Meals using the instructions below. Sign the
statement and return to the center.
If you need help, call the center at _________________________________________________.

Part 1: Participant’s Information: All households complete this part. Print the name of the adult enrolled
at the center.
Part 2A: Households getting Food Stamps, Supplemental Security Income (SSI), or Medicaid: Complete
this part and Parts 3 and 4.
     1. List the current food stamp number, SSI identification number, or Medicaid number for
         the participant. Do not complete Part 2B.
     2. An adult household member must sign the application in Part 4.
Part 2B: All Other Households: Complete this part and Parts 3 and 4.
1.      Write the name of everyone in the household. “Household” means the adult participant and, if
        residing with the participant, the spouse and dependent(s) of the adult participant.
2.      Write the amount of income received last month for each household member. This income is
        the amount before taxes or anything else is taken out. Put the income is the correct column to
        show where it came from, such as earnings, welfare, pensions, and other income. Refer to the
        examples on back for types of income to report. If any amount last month was more or less
        than usual, write that person’s usual income.
3.      An adult household member must sign the application and give his/her social security number in
        Part 4.
Part 3—Racial/Ethnic Identity: Completion of the racial/ethnic section is not mandatory. You are not
required to answer this question to get meal benefits. However, this information will help ensure that
everyone is treated fairly.

Part 4—Signature, Social Security Number, and Certification Statement: All households must complete
this part.
     1. All Applications for Free and Reduced-Price meals must have the signature of an adult household
     2. The adult household member who signs the application must include the last four digits of
         his/her social security number. If he/she does not have a Social Security Number, write “none”
         or state that he/she does not have a Social Security Number. Households getting Food Stamps,
         Supplemental Security Income (SSI), or Medicaid do not have to list a Social Security Number.
     3. The certification statement states that the food stamp, SSI, or Medicaid number is correct or
         that the income reported is complete and accurate.

                                          --continued on back--
                                  TYPES OF INCOME TO REPORT

Earnings from Work                                 Other Income
Wages/Salaries/Tips                                Earnings from a second job
Strike benefits                                    Disability benefits
Unemployment compensation                  Interest/dividends
Workman’s compensation                             Cash withdrawn from savings
NET income for a self -owned business or farm      Income from estates/trusts/investments
                                                   Regular contributions from persons not living in
                                                   the household
Welfare/Child Support/Alimony              Royalties/annuities
Public assistance payments                         Rental Income
Welfare payments                                   Any other Income
Alimony payments
Child support payments

Pensions/Retirement/Social Security
Retirement income
Social Security
Veteran payments
Supplemental Social Security Income

Once properly approved for Free or Reduced-Price meal benefits, a household will remain eligible for
those benefits for a period not to exceed 12 months.