Karamu Nutrition Program

CENTER NAME:(Required)

KNP#: C

Part 1. Children Enrolled For Care

Names of Enrolled Child(ren)(Required)

First Middle Last

Date of Birth(Required)

FOSTER CHILD

DAYS NORMALLY IN CARE

M - F

TIMES NORMALLY IN CARE

From

MEALS NORMALLY FED

Names of Enrolled Child(ren)

First Middle Last

Date of Birth

FOSTER CHILD

DAYS NORMALLY IN CARE

M - F

TIMES NORMALLY IN CARE

From

MEALS NORMALLY FED

Names of Enrolled Child(ren)

First Middle Last

Date of Birth

FOSTER CHILD

DAYS NORMALLY IN CARE

M - F

TIMES NORMALLY IN CARE

From

MEALS NORMALLY FED

Names of Enrolled Child(ren)

First Middle Last

Date of Birth

FOSTER CHILD

DAYS NORMALLY IN CARE

M - F

TIMES NORMALLY IN CARE

From

MEALS NORMALLY FED

*Foster child must be the legal responsibility of a welfare agency or court. If all children listed above are foster children, skip to part 5 to sign this form.

IF YOU ARE USING THIS FORM FOR CHILD ENROLLMENT ONLY, SKIP TO PART 5.*

Part 2. Benefits:

Households which are currently receiving benefits through the Supplemental Nutrition Assistance Program (SNAP) or Families First (FF) Cash Assistance or Families First Child Care Assistance (If your household is now receiving benefits under one or more of these programs, complete this part, and sign the statement in Part 5 - Do not complete Part 4.)

ACCENT Case No. for SNAP, K-TAP or FF Cash Assistance:

(7 to 10 digits)

OR FF Child Care Assistance Case No.:

(5 to 9 digits)

Part 3. Other Source Categorical Eligibility

If any child you are applying for is homeless, migrant, runaway, or participates in Headstart, provide their name(s) and check the appropriate box. Documentation certifying the child's status must be provided with this application.

Categorical Eligibility

Homeless

Migrant

Runaway

Headstart

Part 4. Total Household Gross Income

A. Name

B. Gross Annual Income (Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12)

1. Earnings from work before deductions

2. Welfare, child support, alimony

3. Pensions, retirement, Social Security, SSI, VA benefits

4. All Other Income

$ per Year

Part 5. Signature and Last Four Digits of Social Security Number (Adult household member must sian)

An adult household member must sign this form. If Part 4 is completed, the adult signing the form must also list the last four digits of his or her Social Security Number or mark the "I do not have a Social Security Number" box.

mean mov a no 1 certify that all information on this form is true and that all income is reported. I understand that the center or day care home will get Federal funds based on the information / give. I understand that CACFP officials may verify the information. I understand that if I purposely give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted.

Sign here:(Required)

Print name:(Required)

Date(Required)

Last four digits of Social Security Number: (Only if reporting income in Part 4)

I do not have a Social Security Number

Address:(Required)

Street Address City State ZIP Code

Phone Number:(Required)

Email Address:(Required)

Part 6. Participant's Ethnic and Racial Identities (optional)

Mark one ethnic identity:(Required)

Hispanic or Latino

Not Hispanic or Latino

Mark one or more racial identities:(Required)

Asian

White

Black or African American

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

DO NOT WRITE BELOW THIS LINE - KARAMU STAFF USE ONLY

Eligibility Classification: (Circle) Free Reduced-Price Paid	Basis for Classification: (Circle) Categorically Eligible Income Eligible
Determining Official Signature:______________________	Date:______________________

This institution is an equal opportunity provider.

Part 1. Children Enrolled For Care

IF YOU ARE USING THIS FORM FOR CHILD ENROLLMENT ONLY, SKIP TO PART 5.*

Part 2. Benefits:

Part 3. Other Source Categorical Eligibility

Part 4. Total Household Gross Income

Part 5. Signature and Last Four Digits of Social Security Number (Adult household member must sian)

Part 6. Participant's Ethnic and Racial Identities (optional)

DO NOT WRITE BELOW THIS LINE - KARAMU STAFF USE ONLY

Location 1 (Semmes Street)

Location 2 (Dunn Ave)

Have Questions?

Location 1 (Semmes Street)

Location 2 (Dunn Ave)

Karamu Nutrition Program

Part 1. Children Enrolled For Care

****IF YOU ARE USING THIS FORM FOR CHILD ENROLLMENT ONLY, SKIP TO PART 5.*****

Part 2. Benefits:

Part 3. Other Source Categorical Eligibility

Part 4. Total Household Gross Income

Part 5. Signature and Last Four Digits of Social Security Number (Adult household member must sian)

Part 6. Participant's Ethnic and Racial Identities (optional)

DO NOT WRITE BELOW THIS LINE - KARAMU STAFF USE ONLY

Location 1 (Semmes Street)

Location 2 (Dunn Ave)

Have Questions?

Location 1 (Semmes Street)

Location 2 (Dunn Ave)

IF YOU ARE USING THIS FORM FOR CHILD ENROLLMENT ONLY, SKIP TO PART 5.*