1. Confused by Income Statements ? Mike Ryan Nutrition Program Consultant 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 Begin Using July 1, 2014

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. Part 2: All Other Households Peter - $500 x 52 = $26,000 Karen - $400 x 26 = $10,400 Jim - $100 x 12 = $1200 Jack - $100 x 12 = $1200 $38,800 Peter Smith Karen Smith Joe Smith Jim Cobb Jack Cobb 500 X X X X 100 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 three methods chosen by agency 1.Date agency determines (initials & dates) HSIS 2.Date adult signed/dated HSIS 3.Date HSIS received in agency office (date stamp) ◦ HSIS must be complete at time of submission for methods 2 or 3 to apply

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

31. Household Size-Income Record HSIR good for one year Complete new HSIR each fiscal year (starting October 1 st ) ◦ One HSIR per center DO NOT create a new HSIR each month Print or save each month as documentation for that months’ claim

32. Household Size-Income Record Complete HSIR each month to report total # of FRN on the respective month’s claim File income statements in same order as HSIR Confidential

33. Enrollment Policy Defines what children to include on monthly claim Collected as part of the annual CACFP Application – Site Page Sample policies in Guidance Memorandum #6

34. Names of Enrolled Children

35. Household Size-Income Record List every enrolled child on HSIR according to your center’s enrollment policy including: ◦ Infants ◦ School-age children attending before and after- school ◦ 4K participants Compare attendance records to HSIR

36. Household Size-Income Record Obtain need category (N,R,F) for each child from HSIS’s Indicate need category of each enrolled child on HSIR with N, R, F or X

37. When a Child Leaves the Center When a child is no longer enrolled, do no mark in any need category for the first month after the child has terminated from the center ◦ Draw a line through the months or leave blank Never remove or discard an income statement Never erase a name from the HSIR

39. Adding Newly Enrolled Children to HSIR Paper copy of HSIR: add new children’s names to bottom of form Excel HSIR: add new children alphabetically by inserting rows ◦ Follow instructions exactly for inserting rows

40. Press on the row number (on the left hand side) and select Insert and then Rows from the top menu This will add a row above the row you have clicked on

43. HSIR Edit Checks 1. Compare children on HSIR to attendance records 2. Check need category and effective date of determination from “For Center Use Only" box on each HSIS to need category on HSIR 3. Check that need category is in the correct column for each child

44. HSIR Edit Checks 4. Double check the "Totals" row for each column of need category if completing HSIR by hand 5. Double check the totals for each need category on the monthly claim to assure they have been recorded from the correct column of the HSIR 6. Print off a copy of the Excel HSIR each month

45. HSIS’s for By the Book Day Care  Review the HSIS’s to verify they have been approved correctly.  Compare the HSIS determination (“FOR CENTER USE ONLY” box) to the child’s eligibility marked on the HSIR to verify if they been accurately recorded. 45 Handouts – A through G

46. Nick Goodman 46 Handout - A Correct – This HSIS is valid through 2/28/15, which is 12 months from the Effective Date of the Determination.

47. Correct - The multiple pay frequencies were converted to yearly. $700/bi-weekly x 26 = $18, 200 $225/weekly x 52 = $11,700 $100/monthly x 12 = $ 1,200 $31,100/yearly Jacob Jackson 47 Attachment - B

48. 48 Attachment - C $31,000 yearly for family of 4

49. Incorrect – There is no FS# listed, parent only marked box, did not add FS#. It is not okay if parent only marks box. Grace Lampert 49 Attachment - C Also, cannot use income because parent did not include last 4 digits of social security number. HSIS would be Non-Needy.

50. Incorrect – There is no parent signature or date. HSIS is incomplete and would be Non-Needy. Amy Mann 50 Attachment - D

51. Correct: $275/weekly $150/weekly $425/weekly David Oliver 51 Attachment - E

52. 52

53. Incorrect – The 2 children listed at the top of the HSIS that are enrolled at center were not included as a household member. 53 Attachment - F HSIS is Reduced Darlene Smith Laura Smith 5

54. $3150 monthly for family of 3 would not qualify as Free OR Reduced $3150 monthly for family of 5 54 Attachment - C

55. Correct – Agency called & received information via telephone & initialed and dated, because parent only marked that they received FS but did not write in the FS#. Lori Zander 55 Attachment - G

56. Corrected HSIR Corrected HSIR 56

57. HSIR and Attendance Records for By the Book Day Care Check if all children that attended at least one day in February, per attendance records, are listed on the HSIR for February Note: By the Book Day Care’s CACFP Enrollment Policy is - a child is considered enrolled for a given month if he or she has a completed and approved current enrollment form on file and is in attendance at least one time with in the given month. 57

58. Monthly Attendance Records Compare HSIR to Attendance Records 58 Attachment - HAttachment - I

59. Corrected Attendance Records 59

60. Corrected HSIR Corrected HSIR 60

61. HSIS Effective Date AS OF 7/1/14 - 1 of 3 Methods… 1. Date the Household Size-Income Statement was initialed and dated by the agency’s Determining Official certifying the eligibility determination 2. Date the Household Size-Income Statement was signed and dated by the household member 3. Date the Household Size-Income Statement was submitted, meaning the date the Household Size-Income Statement was received in the agency’s office (date stamped upon receipt by the agency is required) Agency will formalize choice via online application-FFY 2015

62. Effective Date of Determination ◦ Date HSIS becomes effective  12 months maximum ◦ Based one of three methods chosen by agency 1.Date agency determines (initials & date) HSIS 2.Date adult signed/dated HSIS 3.Date HSIS received in agency office (date stamp) ◦ HSIS must be complete at time of submission for methods 2 or 3 to apply

63. CACFP Enrollment Guidance Memo 6C Collect data on each child’s normal days and hours in care, and meals received while in care ◦ DPI Form or agency contract Required for all centers and Head Start sites Exceptions: ◦ Outside of school hours centers ◦ At Risk sites ◦ Emergency shelters

64. PI-6077 or PI-6077-A DPI form(s) used to collect CACFP enrollment data PI-6077 or PI-6077-A ◦ Modified to collect additional information  Infants  Special dietary needs  Ethnic/Racial Data

65. Annual Updates CACFP enrollment data must be annually updated PI-6077 & PI-6077-A both can be used for 3 years ◦ Initial year and 2 yearly updates Agency can collect a new form each year in lieu of annual updates

66. Alternative to CACFP Enrollment Form (PI-6077/PI-6077-A) Daily sign in and out documentation of each child by parent Must capture actual arrival and departure times Must be signed, initialed or entered electronically each day by parents-Not Staff DCF or center enrollment form (i.e. contract) must also be annually updated and signed by parent

67. QUESTIONS?

68. 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!