1. Confused by Income Statements ? Child and Adult Care Food Program Wisconsin Department of Public Instruction Child Care Institutions Outside of School Hours Care Centers Guidance Memorandum #1C Guidance Memorandum #6C http://fns.dpi.wi.gov/fns_centermemos

2. Newly Reformatted HSIS

3. Household Size-Income Statement (HSIS) Income form to determine financial need of child (free, reduced, non-needy) Help determine the amount of reimbursement your agency receives Required to complete Household Size- Income Record

4. Distribute HSIS and Parent Letter Begin CACFP Annual basis New families Collect HSIS back from parents

5. Determining Official Reviews/approves HSIS ◦ Authorized Representative ◦ Food Program Manager ◦ Director ◦ Owner Completes HSIS For Center Use Only FOR CENTER USE ONLY – All 3 sections and the Effective Date must be completed 1) Basis of Determining Eligibility Total Household Size _________ OR  Total Income $_________/_____  FoodShare WI  W-2 Cash Benefits  FDPIR  Foster Child(ren) 2)Eligibility Determination  Free  Reduced  Non-Needy 3) Determining Official’s Initials & Approval Date ______________________________ __ Effective Date of the Determination ______________________________ ______

6. Names of Child(ren) Child’s full name at top of HSIS ◦ First and last name as on attendance records and enrollment forms Siblings may be listed on one HSIS ◦ If different last names, list the first and last name of each child First and Last Name(s) of Enrolled Child(ren) Jim Cobb, Jack Cobb, Joe Smith Center Peaceful Playhouse Day Care Center The Child and Adult Care Food Program HOUSEHOLD SIZE—INCOME STATEMENT (CHILD CARE COMPONENT) (FFY 2015, Rev. 7/14) An adult household member must complete and return to center.

7. Part 1: Benefit Programs Automatically qualifies a child as FREE FoodShare Wisconsin Wisconsin Works Cash Benefits FDPIR (Food Distribution Program on Indian Reservation) PART 1: BENEFITS If any member of your household currently receives FoodShare Wisconsin, Wisconsin Works Cash Benefits, and/or FDPIR (Food Distribution Program on Indian Reservations), check the box for the benefit currently received and provide the case number. Complete PART 3 and return it to the center’s office. Do not complete PART 2. If no one receives these benefits, go to PART 2.  FoodShare Wisconsin (10 or 16 Digit )  Wisconsin Works Cash Benefits (10 Digit )  FDPIR (9 Digit #) Case Number/Quest Card Number: __________________________________________

8. Part 1: Benefit Programs ProgramValid Case Number FoodShare10 digit case number -or- 16 digit Quest card number Wisconsin Works Cash Benefits 10 digit case number FDPIR9 digit case number 1 0 1 1 1 2 1 3 1 4 PART 1: BENEFITS If any member of your household currently receives FoodShare Wisconsin, Wisconsin Works Cash Benefits, and/or FDPIR (Food Distribution Program on Indian Reservations), check the box for the benefit currently received and provide the case number. Complete PART 3 and return it to the center’s office. Do not complete PART 2. If no one receives these benefits, go to PART 2.  FoodShare Wisconsin (10 or 16 Digit #)  Wisconsin Works Cash Benefits (10 Digit #)  FDPIR (9 Digit #) Case Number/Quest Card Number: __________________________________________

9. FREE! FOR CENTER USE ONLY – All 3 sections and the Effective Date must be completed 1) Basis of Determining Eligibility Total Household Size _________ OR  Total Income $_________/_____  FoodShare WI  W-2 Cash Benefits  FDPIR  Foster Child(ren) 2)Eligibility Determination  Free  Reduced  Non-Needy 3) Determining Official’s Initials & Approval Date ______________________________ __ Effective Date of the Determination ______________________________ ______ MB 5/21/14 5/1/2014 ADULT HOUSEHOLD MEMBER SIGNATURE AND LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (SS#) If Part 2 is completed, the adult signing the form must list the last four digits of his/her SS# or check “None” if you do not have a SS#. I CERTIFY that all of the above information is true and correct and that all income is reported. I understand that this information is being given for the receipt of federal funds; that agency officials may verify the information on the application; and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws. Signature of Adult Household Member Signature Date Mo./Day/Yr. Last 4 digits of SS# (or check “None” if you do not have a SS#) ***-**-__ __ __ __  None Randall Cobb 5/20/2014

10. Part 2: All Other Households Households that do not complete Part 1 must complete Part 2

11. Part 2: All Other Households List all household members, including children Report all income and how often it is received Households above Income Eligibility Guidelines may write “NA” in Part 2, and are Non-needy Peter Smith Karen Smith Joe Smith Jim Cobb Jack Cobb 100 500 X X X X X

12. Part 2: All Other Households Adult household member must write name and last 4 digits of Social Security Number ◦ Or indicate by checking the box that he/she does not have SS# If this information is missing the form is incomplete and the statement is Non-Needy ADULT HOUSEHOLD MEMBER SIGNATURE AND LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (SS#) If Part 2 is completed, the adult signing the form must list the last four digits of his/her SS# or check “None” if you do not have a SS#. I CERTIFY that all of the above information is true and correct and that all income is reported. I understand that this information is being given for the receipt of federal funds; that agency officials may verify the information on the application; and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws. Signature of Adult Household Member Signature Date Mo./Day/Yr. Last 4 digits of SS# (or check “None” if you do not have a SS#) ***-**-__ __ __ __  None Karen Smith 4/21/2014 1 2 3 4

13. Determine Total Income Amount Same Pay Frequency - add as is to get one total amount for household for that frequency Multiple Pay Frequencies – convert each to annual amount and add to get one total amount for household Do not round off values resulting from conversion Pay FrequencyConversion WeeklyX 52 Bi-weekly (every 2 weeks)X 26 Twice a monthX 24 MonthlyX 12

14. Household Size-Income Scale Use to determine need category

15. Peter Smith Karen Smith Joe Smith Jim Cobb Jack Cobb 500 100 Part 2: All Other Households Convert to annual income when there are multiple pay frequencies Peter - $500 x 52 = $26,000 Karen - $400 x 26 = $10,400 Jim - $100 x 12 = $1200 Jack - $100 x 12 = $1200 $38,800 X X X X X

16. Household size is 5; yearly income is $38,800 Calculating HSIS

17. Household size is 5; yearly income is $38,800 Calculating HSIS

18. REDUCED! Calculating HSIS FOR CENTER USE ONLY – All 3 sections and the Effective Date must be completed 1) Basis of Determining Eligibility Total Household Size _________ OR  Total Income $_________/_____  FoodShare WI  W-2 Cash Benefits  FDPIR  Foster Child(ren) 2)Eligibility Determination  Free  Reduced  Non-Needy 3) Determining Official’s Initials & Approval Date ______________________________ __ Effective Date of the Determination ______________________________ ______ 5 $38,800 yr MB 5/21/2014 April 2014

19. Foster children are eligible for free meals when the child’s care and placement is responsibility of the State or the child is placed with a caretaker by a court of law Foster Child(ren)

20. Sue Goodman MB 5/21/2014 April 2014

21. Households with foster and non-foster children Foster child(ren) = free Determine remainder of household based on household income or other categorical eligibility If reporting income, the guardian must provide the last four digits of adult’s SS# A child permanently placed in a home is considered a member of the household

22. Households with foster and non-foster children $900 + $480 = $1,380 Every 2 weeks James Winter Susanne Winter Maria Winter Carol Krantz Joseph Krantz 900 480

23. Household Size-Income Scale Family of 5 / $1,380 every two weeks Above income guideline for free Within income guidelines for reduced

24. 5 $1380 bi-wkly Foster children (Carol and Joseph Krantz) = Free Non-foster child (Maria Winter) = Reduced Households with foster and non-foster children MB MM/DD/YY Maria Carol & Joseph MB 5/21/2014 May 2014 $1,300 /bi-wkly 5

25. Part 3 – All Households Parent Signature Required Parent Signature Date Required Income statements not signed and dated by adult household member are INCOMPLETE and must be listed as NON-NEEDY Karen Smith 5/21/2014 1 2 3 4

26. Missing Information? Missing information ◦ Return to parent ◦ Contact parent  Get info over the phone (not parent signature/date)  Record missing information  Who provided info  Date  Your initials HSIS is Non-Needy until it is complete Any changes Cross off invalid info – add correct info-date and initial Do not use white out or “black out”

27. HSIS DETERMINATION Date Date Determining Official reviews and approves the HSIS

28. Effective Date of Determination ◦ Date HSIS becomes effective  12 months maximum ◦ Based one of two methods chosen by agency 1.Date agency determines (initials & dates) HSIS 2.Date adult signed/dated HSIS ◦ HSIS must be complete at time of submission

29. HSIS Valid for 12 Months Valid for 12 months from effective date of the determination ◦ Effective date of determination = October 1; HSIS will expire October 31 st of following year OctNovDecJanFebMarAprMayJunJulAugSepOct 21st31st Form Expires Form Approved

30. QUESTIONS?

31. The U.S Department of Agriculture prohibits discrimination against its customers, employees, and applicants for 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 requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov. http://www.ascr.usda.gov/complaint_filing_cust.htmlprogram.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. Thank you!