Determining Household Size-Income Statements (HSIS)

Confused by Income Statements?Mike RyanNutrition Program ConsultantChild 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

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Newly Reformatted HSIS

Begin Using July 1, 20142Household 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

3Distribute HSIS and Parent LetterBegin CACFPAnnual basisNew familiesCollect HSIS back from parents4Determining OfficialReviews/approves HSISAuthorized RepresentativeFood Program ManagerDirectorOwner

Completes HSIS For Center Use Only

FOR CENTER USE ONLY All 3 sections and the Effective Date must be completed1) 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-Needy3) Determining Officials Initials & Approval Date________________________________ Effective Date of the Determination____________________________________5Names of Child(ren)Childs full name at top of HSIS First and last name as on attendance records and enrollment forms

Siblings may be listed on one HSISIf different last names, list the first and last name of each childFirst and Last Name(s) of Enrolled Child(ren)Jim Cobb, Jack Cobb, Joe SmithCenterPeaceful Playhouse Day Care CenterThe Child and Adult Care Food ProgramHOUSEHOLD SIZEINCOME STATEMENT (CHILD CARE COMPONENT) (FFY 2015, Rev. 7/14)An adult household member must complete and return to center. 6Part 1: Benefit ProgramsAutomatically qualifies a child as FREEFoodShare WisconsinWisconsin Works Cash BenefitsFDPIR (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 centers 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: __________________________________________7Part 1: Benefit ProgramsProgramValid Case NumberFoodShare10 digit case number -or-16 digit Quest card numberWisconsin Works Cash Benefits10 digit case numberFDPIR9 digit case number1 0 1 1 1 2 1 3 1 4PART 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 centers 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: __________________________________________

8FREE!FOR CENTER USE ONLY All 3 sections and the Effective Date must be completed1) 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-Needy3) Determining Officials Initials & Approval Date________________________________ Effective Date of the Determination____________________________________

MB 5/21/14 5/1/2014ADULT 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 Cobb5/20/2014 9Part 2: All Other Households Households that do not complete Part 1 must complete Part 2

10Part 2: All Other Households List all household members, including childrenReport all income and how often it is receivedHouseholds above Income Eligibility Guidelines may write NA in Part 2, and are Non-needy

Peter SmithKaren SmithJoe SmithJim CobbJack Cobb100100500500XXXXX11Part 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-NeedyADULT 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 Smith4/21/2014 1 2 3 4 12Determine 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 FrequencyConversionWeeklyX 52Bi-weekly (every 2 weeks)X 26Twice a monthX 24Monthly X 1213

Household Size-Income ScaleUse to determine need category14Part 2: All Other Households Peter - $500 x 52 = $26,000Karen - $400 x 26 = $10,400Jim - $100 x 12 = $1200Jack - $100 x 12 = $1200 $38,800

Peter SmithKaren SmithJoe SmithJim CobbJack Cobb500500XXXX100100X15Household size is 5; yearly income is $38,800Calculating HSIS

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

17REDUCED!Calculating HSISFOR CENTER USE ONLY All 3 sections and the Effective Date must be completed1) 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-Needy3) Determining Officials Initials & Approval Date________________________________ Effective Date of the Determination____________________________________

5$38,800 yr

MB 5/21/2014April 201418Foster children are eligible for free meals when the childs care and placement is responsibility of the State or the child is placed with a caretaker by a court of law

Foster Child(ren)

19Foster Child(ren)

Sue Goodman

MB 5/21/2014April 201420

Households with foster and non-foster children

Foster child(ren) = freeDetermine remainder of household based on household income or other categorical eligibilityIf reporting income, the guardian must provide the last four digits of adults SS#

A child permanently placed in a home is considered a member of the household

21Households with foster and non-foster children $900 + $480 = $1,380 Every 2 weeks

James WinterSusanne WinterMaria WinterCarol KrantzJoseph Krantz900480

22Household Size-Income Scale

Family of 5 / $1,380 every two weeks

Above income guideline for free

Within income guidelines for reduced235

$1380 bi-wklyFoster children (Carol and Joseph Krantz) = Free Non-foster child (Maria Winter) = Reduced

Households with foster and non-foster children

MB MM/DD/YY

MariaCarol & Joseph MB 5/21/2014May 2014$1,300 /bi-wkly 524Part 3 All HouseholdsParent Signature RequiredParent Signature Date RequiredIncome 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

25Missing Information?Missing informationReturn to parentContact parentGet info over the phone (not parent signature/date)Record missing informationWho provided infoDateYour initialsHSIS is Non-Needy until it is completeAny changesCross off invalid info add correct info-date and initialDo not use white out or black out 26HSIS DETERMINATION DateDate Determining Official reviews and approves the HSIS

27Effective Date of DeterminationDate HSIS becomes effective12 months maximumBased one of three methods chosen by agencyDate agency determines (initials & dates) HSISDate adult signed/dated HSISDate HSIS received in agency office (date stamp)HSIS must be complete at time of submission for methods 2 or 3 to apply

28HSIS Valid for 12 MonthsValid for 12 months from effective date of the determinationEffective date of determination = October 1; HSIS will expire October 31st of following year

OctNovDecJanFebMarAprMayJunJulAugSepOct21st31stForm ExpiresForm Approved29

30Household Size-Income RecordHSIR good for one year

Complete new HSIR each fiscal year (starting October 1st)One HSIR per center

DO NOT create a new HSIR each month

Print or save each month as documentation for that months claim31Household Size-Income RecordComplete HSIR each month to report total # of FRN on the respective months claim

File income statements in same order as HSIR

Confidential32Enrollment PolicyDefines what children to include on monthly claim Collected as part of the annual CACFP Application Site Page

Sample policies in Guidance Memorandum #6

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Names of Enrolled Children34Household Size-Income RecordList every enrolled child on HSIR according to your centers enrollment policy including:InfantsSchool-age children attending before and after-school4K participants

Compare attendance records to HSIR35Household Size-Income RecordObtain need category (N,R,F) for each child from HSISsIndicate need category of each enrolled child on HSIR with N, R, F or X

36When a Child Leaves the CenterWhen 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

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38Adding Newly Enrolled Children to HSIRPaper copy of HSIR: add new childrens names to bottom of form

Excel HSIR: add new children alphabetically by inserting rowsFollow instructions exactly for inserting rows39

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 on40

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42HSIR Edit ChecksCompare children on HSIR to attendance records

Check need category and effective date of determination from For Center Use Only" box on each HSIS to need category on HSIR

Check that need category is in the correct column for each child

43HSIR Edit ChecksDouble check the "Totals" row for each column of need category if completing HSIR by hand

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

444HSISs for By the Book Day CareReview the HSISs to verify they have been approved correctly.

Compare the HSIS determination (FOR CENTER USE ONLY box) to the childs eligibility marked on the HSIR to verify if they been accurately recorded.45Handouts A through G 2011 CACFP Summer Training7/19/201145Nick Goodman46Handout - A

Correct This HSIS is valid through 2/28/15, which is 12 months from the Effective Date of the Determination.2011 CACFP Summer Training7/19/201146Correct - 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/yearlyJacob Jackson47Attachment - B

2012 CACFP Summer TrainingREVISED 7/20/124748Attachment - C

$31,000 yearly for family of 4

2011 CACFP Summer Training7/19/201148Incorrect There is no FS# listed, parent only marked box, did not add FS#. It is not okay if parent only marks box.

Grace Lampert49Attachment - CAlso, cannot use income because parent did not include last 4 digits of social security number. HSIS would be Non-Needy.

2011 CACFP Summer Training7/19/201149Incorrect There is no parent signature or date. HSIS is incomplete and would be Non-Needy.Amy Mann50Attachment - D

2012 CACFP Summer Training7/19/201250Correct:$275/weekly$150/weekly$425/weeklyDavid Oliver51Attachment - E

2012 CACFP Summer TrainingREVISED 7/20/20125152

2011 CACFP Summer Training7/19/201152Incorrect The 2 children listed at the top of the HSIS that are enrolled at center were not included as a household member. 53Attachment - FHSIS is Reduced

Darlene SmithLaura Smith52012 CACFP Summer TrainingREVISED 7/20/201253$3150 monthly for family of 3 would not qualify as Free ORReduced$3150 monthly for family of 5

54Attachment - C

2011 CACFP Summer Training7/19/201154Correct 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 Zander55Attachment - G

2012 CACFP Summer TrainingREVISED 7/20/201255 Corrected HSIR56

2011 CACFP Summer Training7/19/201156HSIR and Attendance Records for By the Book Day CareCheck if all children that attended at least one day in February, per attendance records, are listed on the HSIR for FebruaryNote: By the Book Day Cares 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.572011 CACFP Summer Training7/19/201157Monthly Attendance RecordsCompare HSIR to Attendance Records58Attachment - HAttachment - I

2011 CACFP Summer Training7/19/201158Corrected Attendance Records59

2012 CACFP Summer TrainingREVISED 7/20/201259 Corrected HSIR60

2012 CACFP Summer TrainingREVISED 7/20/201260HSIS Effective DateAS OF 7/1/14 - 1 of 3 Methods

1. Date the Household Size-Income Statement was initialed and dated by the agencys 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 agencys office (date stamped upon receipt by the agency is required)

Agency will formalize choice via online application-FFY 201561Effective Date of DeterminationDate HSIS becomes effective12 months maximumBased one of three methods chosen by agencyDate agency determines (initials & date) HSISDate adult signed/dated HSISDate HSIS received in agency office (date stamp)HSIS must be complete at time of submission for methods 2 or 3 to apply

62CACFP Enrollment Guidance Memo 6CCollect data on each childs normal days and hours in care, and meals received while in careDPI Form or agency contractRequired for all centers and Head Start sitesExceptions:Outside of school hours centersAt Risk sitesEmergency shelters

63PI-6077 or PI-6077-ADPI form(s) used to collect CACFP enrollment dataPI-6077 orPI-6077-AModified to collect additional informationInfantsSpecial dietary needsEthnic/Racial Data

64Annual UpdatesCACFP enrollment data must be annually updatedPI-6077 & PI-6077-A both can be used for 3 yearsInitial year and 2 yearly updatesAgency can collect a new form each year in lieu of annual updatesAlternative to CACFP Enrollment Form (PI-6077/PI-6077-A)Daily sign in and out documentation of each child by parentMust capture actual arrival and departure timesMust be signed, initialed or entered electronically each day by parents-Not StaffDCF or center enrollment form (i.e. contract) must also be annually updated and signed by parent66QUESTIONS?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 individuals 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!

68Thank you!