Dear Parents:
At Kidz Quest ELC we take pride in providing a safe, fun and learning environment where children can learn and grow. Keeping your child healthy by providing nutritious meals is very important to us at our center. This is why Kidz Quest ELC participates in the USDA program called the Child and Adult Food Program (CACFP) which allows us to receive federal support for meals and snacks.
We are asking all parents to participate in this effort at our Center by completing an application. The amount of federal funds we receive is based on information you provide on the application. All of the children in our care benefit from the reimbursements we receive with a nutritious meal.
Completing this form should only take a few minutes of your time. Please be assured that this information is strictly confidential and is only used to determine food program eligibility.
Kidz Quest ELC is proud to be part of this program and we appreciate your cooperation. If you have any questions or need additional information please speak to someone in the front office.
Sincerely,
Management
The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for the 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 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 in the form. Send your completed complaint form or letter by mail to the U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.D. 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 may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).
USDA is an equal opportunity provider and employer.
INSTRUCTIONS:Households that receive Food Stamps, TANF, FDPIR, SSI or Medicaid: Complete the following:
Part I:For family day care home and child care center, list participant’s name and a Food Stamp, TANF, or FDPIR case number. For adult day care, list participant’s name and a Food Stamp, TANF, FDPIR, SSI or Medicaid case number. Note: foster children (children placed in the household by the court system) can be included in this section. A separate form is no longer needed for foster children.
Part II:Skip this part.
Part III:Child care centers only. Provide the normal days and hours your child is in attendance in the center and indicate the meals he/she normally receives while in care.
Part IV:Sign the form. A Social Security Number is not necessary.
Part V:Answer this question if you choose to.
All other Households, including WIC households, complete the following: Part I: For family day care home, child care center or adult day care, list participant’s name. Part II: To report total household income from last month, complete the following: Column A-Name: List the first and last name of each person living in your household as an economic unit. You must indicate yourself and all children living with you (including foster and non-foster children). In the case of an adult participant, the adult participant, and if residing with the adult participant, the spouse and dependent(s) of the adult participant. Attach another sheet if necessary. Column B-Gross Income last month and how often it was received: Next to each person’s name, list each type of income received last month, and how often it was received. Box 1: List the gross income each person earned from work. This is not the same as take-home pay. Gross income is the amount earned before taxes and other deductions. The amount should be listed on your pay stub, or your boss can tell you. Next to the amount, write how often the person got it (weekly, every other week, twice a month, or monthly). Box 2: List the amount each person got last month from welfare, child support, alimony. Box 3: List Social Security, pensions, and retirement. Box 4: List all other income sources including Worker’s Compensation, unemployment, strike benefits, Supplemental Security Income (SSI), Veteran’s benefits IVA benefits), disability benefits, regular contributions from people who do not live in your household. Report net income from self-owned businesses, farming, or rental income. Next to the amount, write how often the person got it. If you are in the Military Housing Privatization Initiative do not include this housing allowance. Column C-Check if no income: If the person does not have any income, check the box. Part III: Child care centers only. Provide the normal days and hours your child is in attendance in the center and indicate the meals he/she normally receives while in care. Part IV: An adult household member must sign the form, and list the last four digits of his/her social security number. Or, mark the box if he/she does not have one. Part V: Answer this question if you choose to. Privacy Act Statement: This explains how we use the information you give us.
SHARING INFORMATION WITH MEDICAID/SCHIP
Dear Parent/Guardian:
If your children qualify for free or reduced price meals, they may also be able to get free or low cost health insurance through Medicaid or the State Children’s Health Insurance Program (SCHIP). Children with health insurance are more likely to get regular health care and are less likely to become sick.
Because health insurance is so important to children’s well-being,the law allows us to tell Medicaid and SCHIP that your children are eligible for free or reduced price meals,unless you tell us not to.Medicaid and SCHIP only use the information to identify children who may be eligible for their programs. Program officials may contact you to offer to enroll your children in this health insurance program. Filling out the CACFP Meal Benefit Income Eligibility Forms does not automatically enroll your children in health insurance.
If you do not want us to share your information with Medicaid or SCHIP, fill out the form below and send it with your Income Eligibility Form to2740 Joe Jerkins Boulevard, Austell, Ga by / / 2022.(Sending in this form will not change whether your children get free or reduced price meals.).