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Income Eligibility Form - New York State Department of …

_____ 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. Is a foster child SECTION A SNAP Case # _____ TANF #_____ FDPIR # _____ Names of _____ Foster Children An adult household member must sign the application before it can be approved.

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 …

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