CACFP Income Eligibility Guidance for Adult Day Care Centers

Parts 1, 2, and 4 of the IEF are required to be completed, except if Medicaid, SSI, or SNAP benefits are documented, then only Parts 1 and 4 are required.

Part 1: Enrollee Information

• List the first and last names of the participant enrolled at the center.
• List the participant’s complete date of birth (month/day/year).
• If the participant receives Medicaid, Supplemental Security Income (SSI), or Supplemental Nutrition Assistance Program (SNAP [formerly Food Stamps]), mark the box provided and enter the appropriate case number in the space provided. Participation in these programs automatically classifies the participant as eligible for free meals, and the family member or the guardian does not need to complete Part 2.

Part 2: Household and Income Information

• Report income by payment cycle (i.e., weekly, monthly, etc.) for each household member.
• List all household members. A household member is defined as the adult participant, and if residing with the adult participant, the spouse and dependents of the adult participant. Functionally impaired adults living with their parents are considered a "family" separate from their parents.
• Report gross wages in the space provided. This includes all income before taxes and before other deductions.
• Report welfare, child support, alimony, pensions, retirement, social security, and other income in the space provided, if applicable.

Part 3: Racial Ethnic Information – Completion Is Voluntary

Part 4: Signature

• Sign the form. If the adult participant cannot sign the form, the guardian must sign the form and indicate the relationship to the adult participant in the space provided.
• For the IEF to be valid, you must provide the last four digits of the participant’s social security number, unless the participant is an SSI, SNAP, or Medicaid recipient. If the participant does not have a social security number, write “none” in the space provided.
• Date the form.
• Print the full name of the participant.
• Provide a complete mailing address.
• Provide home phone number and work phone number.
• The IEF cannot be approved for free or reduced-price meals unless the form is signed and dated by the participant, family member, or legal guardian.
• The participant, family member, or legal guardian must fully complete the IEF. The center representative shall not complete any of the information on the IEF. Exceptions will be granted if the participant is unable to complete the IEF and if no family member or guardian is available to complete the form. In this instance, the center may complete the IEF on the participant's behalf if the participant is categorically eligible for free meals.
• The IEF is effective from the first date of the month that the form was signed and dated.

Note: The participant, family member, or legal guardian completing the IEF must attest to the fact that the information provided is correct, that it is being given in connection with the receipt of federal funds, that institution officials may verify information, and that deliberate misrepresentation may subject the individual to prosecution under applicable state and federal laws.