California Department of EducationChild and Adult Care Food Program
Nutrition Services DivisionNSD 3103 F / DCH 04 (REV. 2/2014)
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INCOME TO REPORT
Earnings from Work
Net income from self-owned
Alimony/child support payments
Supplemental security income
Other Monthly Income/Self-Employment
Cash withdrawn from savings
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.
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.