Determining Household Size-Income Statements (HSIS)

Wisconsin Department of Public InstructionChild and Adult Care Food Program (CACFP)

Child Care Institutions

Outside of School Hours Care Centers

Household Size-Income Statements (HSIS)

• Income eligibility forms are used to determine a child’s need category for monthly reimbursement claims

• Need categories are: free, reduced or non-needy

• Need categories have an impact on the amount of reimbursement received for each month a claim is submitted

Print copies to refer to throughout presentation:

Guidance Memorandum #1C:

http://fns.dpi.wi.gov/fns_centermemos• Household Size-Income Statement• Parent Letter• Household Size-Income Scale

Household Size-Income Statement & Parent Letter

HSIS Parent Letter

Household Size-Income Statement & Parent Letter – Annual Updates

Revision Date

• Revised July each year• DPI will send new forms to your agency and

post revisions on DPI website

Household Size-Income Scale

COLLECTING AND DETERMINING HOUSEHOLD SIZE-INCOME STATEMENTS

Determining Official

• Completed and returned HSIS are ready to be determined and approved

• Designate a “determining official” who is responsible for reviewing and approving all HSIS• Authorized Representative, Food Program

Manager, Director, Owner

After determining the eligibility, the determining official completes the bottom portion of the HSIS in the For Center Use Only box• Household size and total household income or categorical

benefits• Eligibility determination (F,R, N) and • Initials and date of determination

Determining Official

Information on Child(ren)

• The enrolled child’s name should be clearly written at the top of the HSIS • First and last name as it appears on the

attendance records and enrollment forms• If there are siblings, parent may complete one

HSIS listing all siblings’ names at the top of the form • If there are different last names, list the first and

last name of each child

Jim Cob, Jack Cob, Joe Smith ABC Child Development, LLC

PART 1: HOUSEHOLDS RECEIVING ASSISTANCE

Determining Household Size-Income Statements

Part 1: Households Receiving Assistance• Completed by households that receive one of the

following types of assistance1. Food Share Wisconsin (Food Stamps)

2. W-2 (Wisconsin Works) Cash Benefits• Trial Jobs; Community Service Jobs (CSJ); W-2 Transition (W-2 T);

Caretaker of an Infant (CMC); At Risk Pregnancy (ARP)• W-2 Cash Benefits W-2 Child Care Assistance

• W2 Child Care Assistance does NOT automatically qualify a household as free

3. FDPIR (Food Distribution Program on Indian Reservation)

• These are the only assistance programs that automatically classify a child in the FREE category

• Households not participating in one of these assistance programs will need to report income in Part 2

Part 1: Households Receiving Assistance

• Food Share Wisconsin (Food Stamps)• 10 digit case number / 16 digit Quest card number

• W-2 Cash Benefits • 10 digit case number

• FDPIR• 9 digit case number

1 0 1 1 1 2 1 3 1 4

• Households reporting a valid Food Share, W-2 Cash Benefits or FDPIR case number do NOT have to complete Part 2 (income and social security number)

1 0 1 1 1 2 1 3 1 4

MB 12/14/12

Karen Smith 10/17/12

Karen Smith, 123 S. Center Street, Madison, WI 55555

1 0 1 1 1 2 1 3 1 4

PART 2: HOUSEHOLD MEMBERS AND INCOME

Determining Household Size-Income Statements

Household Size and Income(Part 2)

• Households that do not receive any assistance and who did not complete Part 1 are requested to complete Parts 2 and 3

• The adult household member who signs the form MUST write their name and last 4 digits of their Social Security Number, or indicate by checking the box that he/she does not have one.

• If the Social Security Number is missing and the box is not checked, the statement must be determined as Non-needy until the month proper information is obtained.

• Households whose income is above the Income Eligibility Guidelines may write “NA” in Part 2. These statements are classified as Non-needy.

Karen smith 1 2 3 4

Household Size and Income (Part 2)

Household Size and Income

• All household members must be listed, including the children whose names are on the top of the HSIS

• All income received in the month prior to completing the income statement must be reported

Peter SmithKaren smithJoe SmithJim CobJack Cob

500 Week400 Bi-weekly

100 Month100 Month

Karen Smith 1 2 3 4

3532275

• Convert incomes to yearly income when multiple pay periods or pay frequencies are reported:

Multiply Weekly X 52Multiply Every 2 weeks X 26Multiply Twice a month X 24Multiply Monthly X 12

• Compute household’s total yearly income

• Compare total income to the Household Size-Income Scale to determine the need category

Computing Monthly Income

3532275

Peter SmithKaren smithJoe SmithJim CobJack Cob

500 Week400 Bi-weekly

100 Month100 Month

Karen Smith 1 2 3 4

• Peter - $500 x 52 = $26,000• Karen - $400 x 26 = $10,400• Jim & Jack -($100 + $100 = $200)

$200 x 12 = $2,400

$38,800

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

Household Size-Income Scale

Household size is 5; yearly income is $38,800Household Size-Income Scale

REDUCED!

5MB 10/04/12

$38,800 yr

Kathy HartTom hartEdward hartWanda hartEmily will

500 Bi-weekly

400 Bi-weekly

Kathy hart 28 14

$900 Every 2 Weeks$500 + $400

3532275

Household size is 5; every 2 week income is $900

Household Size-Income Scale

FREE!

5MB 10/21/12

$900 bi-wkly

Zero ($0) Income

Betsy Walker 4 6 3 4

Betsy WalkerTodd WalkerBen Walker

2652

Income: $0

• Households that report “zero” ($0) income may be approved in the Free category for one year from the date of the determining official’s approval

$0 Income - FREE

3

$0MB 11/3/12

• Foster children are categorically eligible for free meals when the child’s care and placement is the responsibility of the State, or who is placed with a caretaker by a court of law

• This eligibility does not extend to other non-foster child(ren) in the household• Households with foster and non-foster child(ren)

may complete one HSIS and include the foster child(ren) as a household member. This may help the foster family’s non-foster child(ren) qualify for free or reduced prices meals based on household size and income

Foster Child(ren)

Carol and Joseph Krantz

Foster Child(ren)

MB 10/21/12

Suzanne Winter, 123 S. Center Street, Madison, WI 55555

Suzanne Winter

9/11/12

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

Households with foster and non-foster children

James winterSuzanne WinterMaria winter

Carol KrantzJoseph Krantz

900 Bi-weekly

460 Bi-weekly

Suzanne Winter 8 6 2 9

3532275$900 + $460 = $1,360 Every 2 weeks

Household Size-Income ScaleHousehold size is 5; every 2 week income is $1,360

Household Size-Income ScaleHousehold size is 5; every 2 week income is $1,360

5MB 10/21/12

$1360 bi-wkly

Foster children (Carol and Joseph Krantz) = Free Non-foster child (Maria Winter) = Reduced

Carol & Joseph Maria

Households with foster and non-foster children

PART 3: ALL HOUSEHOLDS

Determining Household Size-Income Statements

Part 3 – All Households

Karen Smith 10/17/12

Karen Smith, 123 S. Center Street, Madison, WI 55555

555-1234

Parent/Guardian Signature Required

Parent/Guardian Signature DATE

Required

Income statements that are not signed and dated by an adult household member are INCOMPLETE applications and must be listed in the Non-Needy category

REMINDERSDetermining Household Size-Income Statements

Validity of HSIS

• HSIS becomes effective the month in which the Determining Official initials and dates the form

• HSIS is valid for a maximum of 12 months from the date of the determining official’s approval• Statement approved on June 15th will expire June

30th of following year

Dates on Income Statements

• Collect new income statements from each household at the same time each year • Usually in September or October

• This will reduce the chance that a child would accidentally be reported in the Free or Reduced category with an expired Household Size-Income Statement on file

Need Categories• Free

• Households receiving assistance from qualifying program(s)• Monthly household income for household size is at or below

the USDA income scale for FREE• Foster child

• Reduced• Monthly household income for household size is within the

USDA income scale for REDUCED

• Non-Needy• Monthly household income for household size is above

USDA income scale for reduced or adult household member writes “N/A” or “Does Not Qualify” on form

• Adult household member refuses to complete the form• Adult household member fails to return the form• Form is incomplete (e.g. missing adult signature or date)

Income Statement Reminders• Income statement must be complete• If information is missing, contact the

household• If you need to make a change to a

statement, do not use white-out • With the exception of the signature and

date, it is acceptable to obtain information over the phone to complete the HSIS• Must make a notation on the HSIS of how the

information was obtained, from whom the information was received, the date it was received and your initials

Income Statement Reminders

• Until the month the HSIS is correctly completed and determined, the child must be considered Non-needy

• The Determining Official must complete the information in the “For Center Use Only” box including initials and date for the HSIS to become effective

What’s Next:

Maintaining the Household Size-Income Record (HSIR)

In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability.

To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired 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.