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MEAL BENEFIT FORM FOR PARENTS (TIER II HOMES) - page 4 / 4

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California Department of EducationChild and Adult Care Food Program

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

PAGE 4 of 4

INCOME TO REPORT

Earnings from Work

Wages/salaries/tips

Strike benefits

Unemployment Compensation

Worker’s Compensation

Net income from self-owned

Alimony/Child Support

Alimony/child support payments

Pensions/Retirement/Social Security

Pensions

Supplemental security income

Retirement income

Veteran’s payments

Social Security

Other Monthly Income/Self-Employment

Disability benefits

Cash withdrawn from savings

Interest dividends

Interest from:

Estates/trusts/investments

Regular contributions from persons not living in household

Net royalties/annuities/net income rental

Military allowance for off-base housing

Foster child(ren)’s personal use income (may include income from child’s family for personal use or income earned by child)

Any other income

Part 4–Signature and Certification

a)Print the name of the household member signing this form.

b)The form must have the signature of an adult household member.

c)The adult household member who signs the statement must include the last four digits of his/her Social Security Number. If (s)he does not have a Social Security Number, check the “I do not have a Social Security Number” box. A Social Security Number is not needed if you listed a CalFresh, CalWORKs, Kin-GAP, or FDPIR case number.

Part 5–Racial/Ethnic Identity: You are not required to answer this question to get meal benefits, but completion of this information will assist with the fair and equitable treatment of all participants.  

a)Ethnicity:

1)Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central America, or other Spanish culture or origin, regardless of race. The term “Spanish origin” can be used in addition to “Hispanic or Latino.”

2)Not Hispanic or Latino.

b)Race: Select one or more.

1)American Indian or Alaskan Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

2)Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

3)Black or African American: A person having origins in any of the black racial groups of Africa. Terms such as “Haitian” or “Negro” can be used in addition to “Black or African American.”

4)Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

5)White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

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