X hits on this document

Word document






2 / 4

California Department of EducationChild and Adult Care Food Program

Nutrition Services DivisionNSD 3103 F / DCH 04 (REV. 2/2014)

PAGE 2 of 4

Part 4–Signature and Certification

PENALTIES FOR MISREPRESENTATION: I certify that all of the above information is true and correct and that the CalFresh, CalWORKs, FDPIR, or Kin-GAP, or other eligible program case number is current, correct, or 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 Meal Benefit Form and that the deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws.

Printed Name of Adult:


Signature of Adult:

Last four digits of Social Security Number (SSN):

I do not have a Social Security Number


City/State/Zip Code:

Daytime Phone Number:

Part 5–Racial/Ethnic Identity (Optional)


Hispanic or Latino

Not Hispanic or Latino

Race (select one or more):

American Indian or Alaska Native


Black or African American

Native Hawaiian or Other Pacific Islander


The U.S. Department of Agriculture (USDA) 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 if 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 http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 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. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov. Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint please contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).

Persons with disabilities who wish to file a program complaint, please see information above on how to contact us by mail directly or by email. If you require alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA's TARGET Center at (202) 720-2600 (voice and TDD).

USDA is an equal opportunity provider and employer.

Please note: The protected classes for the Child and Adult Care Food Program are race, color, national origin, age, sex, and disability.

Privacy Act Statement: Unless you list a CalFresh, CalWORKs, FDPIR, or Kin-GAP case number, Section 9 of the National School Lunch Act (NSLA) requires that you include the last four digits of the SSN for the household member signing the form, or indicate that the household member signing the form does not have a SSN. You do not have to list the last four digits of a SSN, but if they are not listed, or the “Check I do not have a Social Security Number” is not marked, we cannot approve the participant Tier I reimbursement. The last four digits of the SSN may be used to identify the household member in verifying the correctness of the information stated on the form. This may include program reviews, audits and investigations, and may include contacting employers to determine income, contacting a CalFresh, CalWORKs, FDPIR, or Kin-GAP office to determine current certification for CalFresh, CalWORKs, FDPIR, or Kin-GAP benefits, contacting the State employment security office to determine the amount of benefits received, and checking the documentation produced by the household member to prove the amount of income received. These efforts may result in a loss or reduction of benefits, administrative claims, or legal actions if incorrect information is reported. The last four digits of the SSN may also be disclosed to programs as authorized under the NSLA and the Child Nutrition Act, the Comptroller General of the United States, and law enforcement officials for the purpose of investigating violations of certain federal, state, and local education, and health and nutrition programs.

Day Care Home Sponsor Use Only

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly x 12

Enter Total Gross Income below, and check the frequency it is received:

$ Weekly      Every 2 Weeks   Twice a Month      Monthly     Annually

Categorical Eligibility:





Foster Child                National School Lunch Program  

Head Start   Early Start Even Start

Child (ren) eligible for Tier I       Tier II reimbursement.     

Printed Name:

Certification Date:


This form must be signed and dated by the agency’s official

Document info
Document views16
Page views16
Page last viewedThu Jan 19 00:27:46 UTC 2017