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Income Eligibility Form

_____ NEW YORK STATE DEPARTMENT OF HEALTH Income Eligibility Form Child and Adult Care Food Program for Child Care Centers See INSTRUCTIONS on reverse. CHILD CARE CENTER NAME _____ Print the name of the child(ren) enrolled in this child care center 1. _____ DIRECTIONS Complete SECTION A if anyone in your household 1. Participates in the Supplemental Nutrition Assistance Program (SNAP) 2. Receives Temporary Assistance to Needy Families (TANF) 3. Participates in the Food Distribution Program on Indian Reservations (FDPIR) OR 4.

or boarding house, but who are living as one economic unit. ... Complete this section if you did not complete Section A. Write in your name and the names of all other adults and children living in the household, including unrelated people, even if they do not have any income. Do not include the children in child care who are listed at the top ...

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