Household Size- Income Statements (HSIS) Child and Adult Care Food Program (CACFP) Wisconsin Department of Public Instruction Child Care Institutions Outside of School Hours Care Centers

Print these forms NOW: Household Size-Income Statement Parent Letter Household Size-Income Scale Guidance Memorandum #1C: nutrition/cacfp/child-care/memos

Household Size-Income Statement (HSIS) Required for children claimed free or reduced Income form to determine financial need of child (free, reduced, non-needy) Required for Household Size-Income Record

Parent Letter Provides information about CACFP eligibility and completing the income statement Income scale to help determine free or reduced eligibility

Household Size-Income Scale July 1, 20XX to June 30, 20XX

Annual Updates July 1, 20XX to June 30, 20XX INCOME SCALE PARENT LETTER INCOME STATEMENT

Distribute HSIS and Parent Letter Begin CACFP New families Annual basis Collect HSIS back from parents

HSIS Parent Letter Name of Center Authorized Representative signature

REVIEWING AND DETERMINING HSIS

Determining Official Reviews, approves and determines HSIS Authorized Representative Food Program Manager Director Owner Completes HSIS For Center Use Only FOR CENTER USE ONLY – All 3 sections and the Effective Date must be completed 1) Basis of Determining Eligibility Total Household Size _________ OR  Total Income $_________/_____  FoodShare WI  W-2 Cash Benefits  FDPIR  Foster Child(ren) 2)Eligibility Determination  Free  Reduced  Non-Needy 3) Determining Official’s Initials & Approval Date ______________________________ __ Effective Date of the Determination ______________________________ ______

Names of Child(ren) Child’s first and last name Siblings may be listed on one HSIS If different last names, list the first and last name of each child First and Last Name(s) of Enrolled Child(ren) Jim Cobb, Jack Cobb, Joe Smith Center Peaceful Playhouse Day Care Center The Child and Adult Care Food Program HOUSEHOLD SIZE—INCOME STATEMENT (CHILD CARE COMPONENT) (FFY 2015, Rev. 7/14) An adult household member must complete and return to center.

Part 1: Benefits Automatically qualifies a child as FREE SNAP (FoodShare Wisconsin) Wisconsin Works (W-2) Cash Benefits FDPIR (Food Distribution Program on Indian Reservation) PART 1: BENEFITS If any member of your household currently receives FoodShare Wisconsin, Wisconsin Works Cash Benefits, and/or FDPIR (Food Distribution Program on Indian Reservations), check the box for the benefit currently received and provide the case number. Complete PART 3 and return it to the center’s office. Do not complete PART 2. If no one receives these benefits, go to PART 2.  FoodShare Wisconsin (10 or 16 Digit )  Wisconsin Works Cash Benefits (10 Digit )  FDPIR (9 Digit #) Case Number/Quest Card Number: __________________________________________

Part 1: Benefits PART 1: BENEFITS If any member of your household currently receives FoodShare Wisconsin, Wisconsin Works Cash Benefits, and/or FDPIR (Food Distribution Program on Indian Reservations), check the box for the benefit currently received and provide the case number. Complete PART 3 and return it to the center’s office. Do not complete PART 2. If no one receives these benefits, go to PART 2.  FoodShare Wisconsin (10 or 16 Digit #)  Wisconsin Works Cash Benefits (10 Digit #)  FDPIR (9 Digit #) Case Number/Quest Card Number: __________________________________________ Wisconsin Shares – Child Care Subsidy is NOT a Wisconsin Works Cash Benefits program

FREE! FOR CENTER USE ONLY – All 3 sections and the Effective Date must be completed 1) Basis of Determining Eligibility Total Household Size _________ OR  Total Income $_________/_____  FoodShare WI  W-2 Cash Benefits  FDPIR  Foster Child(ren) 2)Eligibility Determination  Free  Reduced  Non-Needy 3) Determining Official’s Initials & Approval Date ______________________________ __ Effective Date of the Determination ______________________________ ______ ADULT HOUSEHOLD MEMBER SIGNATURE AND LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (SS#) If Part 2 is completed, the adult signing the form must list the last four digits of his/her SS# or check “None” if you do not have a SS#. I CERTIFY that all of the above information is true and correct and that all income is reported. I understand that this information is being given for the receipt of federal funds; that agency officials may verify the information on the application; and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws. Signature of Adult Household Member Signature Date Mo./Day/Yr. Last 4 digits of SS# (or check “None” if you do not have a SS#) ***-**-__ __ __ __  None Randall Cobb 10/16/20XX

Households that complete Part 1 and report a valid case number do NOT have to complete Part

Part 2: Total Household Size and Income Households that do not complete Part 1 must complete Part 2

Part 2: Total Household Size and Income List all household members Peter Smith Karen Smith Joe Smith Jim Cobb Jack Cobb X X X X X Report all gross income and how often it is received

Same Pay Frequency – add all reported income to get one total amount for that frequency Multiple Pay Frequencies – convert each to annual amount and add to get one total amount for household Do not round values resulting from conversion Determine Total Income Amount

FOR CENTER USE ONLY – All 3 sections and the Effective Date must be completed 1) Basis of Determining Eligibility Total Household Size _________ OR  Total Income $_________/_____  FoodShare WI  W-2 Cash Benefits  FDPIR  Foster Child(ren) 2)Eligibility Determination  Free  Reduced  Non-Needy 3) Determining Official’s Initials & Approval Date ______________________________ __ Effective Date of the Determination ______________________________ ______ Reporting Zero ($0) Income Betsy Walker Todd Walker Ben Walker 3 $0 $0 income is determined as FREE

Households above Income Eligibility Guidelines Determined as Non-needy Not required to turn in a HSIS Above Guidelines N/A

Foster children are eligible for free meals when the child’s care and placement is responsibility of the State or the child is placed with a caretaker by a court of law Foster Child(ren) A child permanently placed in a home is considered a member of the household, not a foster child

Households with foster and non-foster children Determine non-foster children based on benefits or household size and income Can include foster child as a household member

Kinship Care is Not Foster Care Kinship Care is when children reside with a relative rather than be placed in a foster home or other type of out-of-home placement Must complete HSIS Part 1 – qualifying assistance program OR Part 2 – report income

Part 3: All Households Karen Smith 5/21/20XX Signature Required Date Required Social Security Number Required when completing Part 2

HSIS is Incomplete When… Box indicating benefit program is not checked Missing or invalid case number Part 1: Benefits Parent does not report income and the “Check if no income” box is not checked Parent does not indicate pay frequency Missing household members/income Part 2: Total Household Size and Income Missing parent/guardian signature Parent/guardian does not date the form Missing social security number when Part 2 is completed Part 3: All Households These statements are NON-NEEDY until complete information is obtained

Obtain Missing Information Return to or contact parent Get info over the phone (not parent signature/date) Record missing information Who provided info Date Your initials Any changes Cross off invalid info Do not use white out HSIS is Non-Needy until it is complete

HSIS DETERMINATION AND EFFECTIVE DATE

HSIS Effective Date Date of Determining Official Approval Household Member Signature Date CHOOSE ONE

Date of Determining Official Approval FOR CENTER USE ONLY – All 3 sections and the Effective Date must be completed 1) Basis of Determining Eligibility Total Household Size _________ OR  Total Income $_________/_____  FoodShare WI  W-2 Cash Benefits  FDPIR  Foster Child(ren) 2)Eligibility Determination  Free  Reduced  Non-Needy 3) Determining Official’s Initials & Approval Date ______________________________ __ Effective Date of the Determination ______________________________ ______ 10/XX MB 10/20/20XX Date DO reviews, determines and approves the HSIS

FOR CENTER USE ONLY – All 3 sections and the Effective Date must be completed 1) Basis of Determining Eligibility Total Household Size _________ OR  Total Income $_________/_____  FoodShare WI  W-2 Cash Benefits  FDPIR  Foster Child(ren) 2)Eligibility Determination  Free  Reduced  Non-Needy 3) Determining Official’s Initials & Approval Date ________________________________ Effective Date of the Determination ________________________________ ____ Household Member Signature Date Date the Household Size-Income Statement was signed and dated by the adult household member HSIS must be complete at time of submission for this method to apply Agency may NEVER date the income statement for the parent/guardian MB 5/21/20XX 4/XX 4/16/20XX Karen Smith 1234

Household Member Signature Date Examples Parent signature date February DO determination date March Effective Date of Determination February Parent signature date February DO determination date April Effective Date of Determination April

After ALL missing information is obtained Determine the form free, reduced or non-needy Effective Date of Incomplete Forms Completed AFTER Initial Submission FOR CENTER USE ONLY – All 3 sections and the Effective Date must be completed 1) Basis of Determining Eligibility Total Household Size _________ OR  Total Income $_________/_____  FoodShare WI  W-2 Cash Benefits  FDPIR  Foster Child(ren) 2)Eligibility Determination  Free  Reduced  Non-Needy 3) Determining Official’s Initials & Approval Date ______________________________ __ Effective Date of the Determination ______________________________ ______ 12/XX MB 12/20/20XX

Using Date of Determination for Entire Federal Fiscal Year Must choose one method for ALL complete HSIS Indicate in online contract Consistently apply to all HSIS for entire federal fiscal year (October 1 – September 30)

HSIS Valid for 12 Months From Effective Month of Determination OctNovDecJanFebMarAprMayJunJulAugSepOct X 31st Form Expires Effective Month of Determination Example Effective Month of Determination = October HSIS will expire October 31 st of following year 10/20XX

Collect New HSIS Annually Collect new statements from all families Same time each year Prevent incorrectly reporting a child as Free or Reduced with an expired HSIS on file Do this in October!

What to do Next Watch Household Size-Income Record (HSIR) webcast

The U.S Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at or at any USDA office, or call (866) to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C , by fax (202) or at Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer. Thank you!