Enclosure C1
Food Form
Dear Parent or Guardian:
The Salvation Army Wonderland Camp serves nutritious meals to children without an additional charge. This
is possible because reimbursement is received for meals served in accordance with regulations governing the
USDA Summer Food Service Program (SFSP). To document eligibility for these funds, statements of
household size and income must be obtained from parents or guardians. This information is kept confidential.
The Salvation Army Wonderland Camp requires all families to fill out this form, regardless of
eligibility.
Household Size
Monthly Income Level
Effective July 1, 2009, through
June 30, 2010
1
$1,670
2
2,247
3
2,823
4
3,400
5
3,976
6
4,553
7
5,130
8
5,706
For each additional
household member add
577
For families receiving Food Stamps, Public Aid, or Medicaid, a complete application must include: a)
the name of the child applicant; b) the appropriate case number for the child; and c) the signature of an adult
member of the household.
For families not receiving Food Stamps, Public Aid, or Medicaid, a complete application must include:
a) the name of the child applicant and also of all other household members; b) the social security number of
the adult household member signing the application or an indication that a social security number is not
available; c) the household income received by each household member identified by source of income; and d)
the signature of an adult member of the household.
For foster children: a) the foster child applicant is reported as a household of one on the income statement
(income is monthly allowance child receives as spending money); b) the guardian should provide a social
security number and sign the bottom.
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited form discrimination
on the basis of race, color, national origin, sex, age, or disability.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400
Independence Avenue, S.W., Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal
opportunity provider and employer.
Enclosure C2
HOUSEHOLD SIZE-INCOME STATEMENT
APPLICATION STATEMENT OF HOUSEHOLD SIZE-INCOME FOR THE SUMMER FOOD SERVICE PROGRAM (SFSP)
INSTRUCTIONS: An adult household member must complete and return to sponsor. (Rev. 1/02)
Name of Child 1,2
Nutrition Site
FOSTER CHILDREN: In certain cases, meals served to foster children are eligible for reimbursement regardless of the household income. If you have
foster children living with you and wish to apply for benefits for them, complete this application as if for a household of one. Only report income personally
received by the child. Complete a separate application for each foster child.
PART I — HOUSEHOLDS RECEIVING FOOD STAMPS, FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATION (FDPIR), OR WISCONSIN
WORKS (W-2)1 If you are NOW receiving food stamps, W-2 Cash Benefits, and/or FDPIR for these children, you only have to give your Food Stamp, W-2
Cash Benefits, or FDPIR case number. Review PART 3, sign the form and return it to the sponsor’s office. Do not complete PART 2.
YES, I received food stamps, W-2 Cash Benefits, and/or FDPIR this month for this child. Food Stamp Case No. is: _______________or W-2
Cash Benefits Case No. is: ________, or FDPIR Case No is ________.
PART 2— ALL OTHER HOUSEHOLDS--If you did not give a Food Stamp, W-2 Cash Benefits, and/or FDPIR number, you MUST complete the
following information or your application cannot be approved.
HOUSEHOLD MEMBERS: List below the names of everyone living in your household; include yourself and the child listed above.
SOCIAL SECURITY NUMBER: The National School Lunch Act requires that, unless a food stamp, W-2, or FDPIR case number is provided, you must
include a social security number on the application. This may be either the social security number of the household’s primary wage earner or the adult
household member signing the application. If neither person has a social security number, print “none” next to his/her name. Provision of a social
security number is not mandatory, but if a social security number is not provided or an indication is not made that the person does not possess one, the
application cannot be approved. The social security number may be used for verifying the information you report on this application. Verification may
include audits, investigations, contacting the state employment security office and employers, and checking the written information provided by the
household to confirm the information received. If incorrect information is discovered, a loss of benefits or legal action may occur. These facts must be told
to the household member whose social security number is reported on this form.
Name and Social Security Number of primary wage earner or household member who signs this form. 2
Name ________________________________________________
Social Security Number ____ ____ ____ - ___ ___- _____ ____ ____ ____
INCOME: List all income received last month on the same line with the person who received it. List gross income under each category BEFORE
deductions for taxes, social security, etc. Use the following conversion factors to determine monthly income: Weekly income x 4.33 = Monthly income
Biweekly income x 2.165 =Monthly income.
LIST ALL HOUSEHOLD MEMBERS
Name (Last, First) 2
3.
_______________________
_______________________
_______________________
4.
_______________________________
5.
_______________________________
1.
2.
Age
Earnings from Work
(Before Deductions)
____
____
____
____
____
_____________
_____________
_____________
_____________
_____________
MONTHLY INCOME2
Welfare Payments
Payments from
Child Support
Pension,
and/or Alimony
Retirement Social
Security
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
All Other Income
Received Last
Month
_____________
_____________
_____________
_____________
_____________
PART 3 — ALL HOUSEHOLDS
RACIAL/ETHNIC IDENTITY: This information is strictly for statistical reporting. You are not required to answer these questions. If you choose to do so:
Please mark one of the following racial identities:
American Indian or Alaska Native
Asian
Please mark one of the following ethnic identities:
Hispanic or Latino
Black or African American
Native Hawaiian or Other Pacific Islander
White
Not Hispanic or Latino
I CERTIFY that all of the above information is true and correct and that all income is reported unless eligibility is established by receiving food stamps, W-2
Cash Benefits and/or FDPIR. I understand that this information is being given for the receipt of the 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. The signature on this application is that of an adult household member.
Print Name and Address Street, City, ZIP
Signature of Adult Household Member
1,2
Date Mo./Day/Yr
Telephone Number:
Work:
Home:
X
FOR OFFICIAL USE ONLY
Basis for Eligibility Determination
Eligibility Determination
Determining Official’s
Initials and Date
Total Household Size = __________ Total Monthly Income
OR
Needy
Food Stamp/W-2 Cash Benefits/FDPIR Recipient
Non-Needy
Information must be provided by applicant if establishing eligibility as a household now receiving food stamps, W-2 Cash Benefits, or FDPIR
2
Information must be provided by applicant if establishing eligibility as a household not now receiving food stamps, W-2 Cash Benefits, or FDPIR.
1