California Department of EducationChild and Adult Care Food Program
Nutrition Services DivisionNSD 3103 F / DCH 04 (REV. 2/2014)
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INSTRUCTIONS FOR COMPLETING THE
MEAL BENEFITS FORM FOR PARENTS (TIER II HOMES)
If you need help, please call:
Name of Day Care Home Provider
a)Print your name.
Part 1–Children’s Information
a)Print the name(s) of your child(ren) enrolled in care and their birthdate(s).
b)If your child is a foster child, check the box to the right of the child’s birthdate in the column marked “Foster Child.”
c)If your child(ren) participate(s) in Head Start, Early Start, or Even Start programs; or receive(s) free or reduced meals in the National School Lunch Program, check the appropriate box in the column marked “HS/ES/EvS/NSLP.” These children qualify for Tier I reimbursement. It does not qualify the provider as a Tier I home.
Part 2–Categorical Eligibility (Household): If anyone in your household receives CalFresh (formerly Food Stamps), CalWORKs, Kin-GAP, or FDPIR; complete Part 2, and sign the form in Part 4. Do not complete Part 3.
a)Print the benefit recipient’s name. Only one benefit recipient is needed.
b)Check the box corresponding with the program that qualifies the household for higher reimbursement.
c)Write the CalFresh, CalWORKs, Kin-GAP, or FDPIR case number.
d)Skip Part 3. Complete Part 4. Part 5 is optional.
All children in the household are categorically eligible for Tier I reimbursement if any member of the household receives CalFresh, CalWORKs, Kin-GAP, or FDPIR benefits.
Part 3–Income Eligibility: Complete this section if you do not receive benefits listed in Part 2.
a)Print the names of all household members not listed in Part 1. Do not list the children in care. Include household members even if they do not have income. Include yourself, your spouse, or your significant other, and all other household members such as your grandmother, etc. if they are part of your household.
b)Write the amount of income each person received before taxes or any other deductions were made, and how often it was received. If no income, indicate no income. Do not leave blank. Each income amount should be entered in the appropriate column on the form. If you have foster children in your care and are completing this section to qualify other children for higher reimbursement, list any personal use income of the foster child. Foster payments you receive from the placing agency for the care of the child do not need to be reported.
c)If anyone is self-employed, write the amount of income that person earns from self-employment. Call the number listed at the top of the form if you need assistance.
d)If your household currently has no income, check the box marked, “Check here if no household income.”
e)Enter the total number of household members. Count the children in Part 1 and the household members in Part 3.
f)Go to Part 4.