Confused by Income

Statements?

Child and Adult Care Food ProgramWisconsin Department of Public Instruction

Child Care InstitutionsOutside of School Hours Care Centers

Guidance Memorandum #1CGuidance Memorandum #6Chttp://fns.dpi.wi.gov/fns_centermemos

Newly Reformatted HSIS

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

Distribute HSIS and Parent Letter

Begin CACFPAnnual basisNew families

Collect HSIS back

from parents

Determining OfficialReviews/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 DeterminationFree Reduced

Non-Needy

3) Determining Official’s Initials & Approval Date

________________________________ Effective Date of the Determination

____________________________________

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

CenterPeaceful Playhouse Day Care Center

The Child and Adult Care Food ProgramHOUSEHOLD SIZE—INCOME STATEMENT (CHILD CARE COMPONENT) (FFY 2015, Rev. 7/14)An adult household member must complete and return to center.

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: BENEFITSIf 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: __________________________________________

Part 1: Benefit Programs

Program Valid Case Number

FoodShare 10 digit case number -or-16 digit Quest card number

Wisconsin Works Cash Benefits

10 digit case number

FDPIR 9 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: __________________________________________

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 DeterminationFree 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#)***-**-__ __ __ __ NoneRandall Cobb 5/20/2014

Part 2: All Other Households Households that do not complete Part 1

must complete Part 2

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 SmithKaren SmithJoe SmithJim CobbJack Cobb

100100

500500

X

X

X

X

X

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#)***-**-__ __ __ __ NoneKaren Smith 4/21/2014 1 2 3 4

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 Frequency Conversion

Weekly X 52

Bi-weekly (every 2 weeks)

X 26

Twice a month X 24

Monthly X 12

Household Size-Income Scale

Use to determine need category

Peter SmithKaren SmithJoe SmithJim CobbJack Cobb

500500

100100

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

Household size is 5; yearly income is $38,800

Calculating HSIS

Household size is 5; yearly income is $38,800

Calculating HSIS

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 DeterminationFree Reduced

Non-Needy

3) Determining Official’s Initials & Approval Date

________________________________ Effective Date of the Determination

____________________________________

5$38,800 yr

MB 5/21/2014April 2014

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)

Foster Child(ren)

Sue Goodman

MB 5/21/2014

April 2014

Households with foster and non-foster children

Foster child(ren) = freeDetermine 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

Households with foster and non-foster children

$900 + $480 = $1,380 Every 2 weeks

James WinterSusanne WinterMaria WinterCarol KrantzJoseph Krantz

900480

Household Size-Income Scale

Family of 5 / $1,380 every two weeks

Above income guideline for free

Within income guidelines for reduced

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/YYMaria

Carol & Joseph MB 5/21/2014

May 2014$1,300 /bi-wkly

5

Part 3 – All Households

Parent Signature

RequiredParent 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

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”

HSIS DETERMINATION Date

Date Determining Official reviews and approves the HSIS

Effective Date of Determination

◦ Date HSIS becomes effective 12 months maximum

◦ Based one of two methods chosen by agency1. Date agency determines (initials & dates) HSIS2. Date adult signed/dated HSIS

◦HSIS must be complete at time of submission

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 31st of following year

Oct Nov

Dec Jan Feb Ma

r Apr May Jun Jul Au

gSep Oct

21st

31st

Form

ExpiresForm

Approved

QUESTIONS?

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. 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!