CACFP Meal Benefit Income Eligibility Parent Letter Non Pricing Fillable

Child and Adult Care Food Program Meal Benefit Income Eligibility Letter (Child Care Non-Pricing) FY 2023

Dear Parent/Gaudian:

_N_a_m_e_o_f_C_e_n_t_er______________ offers healthy meals and snacks to children as part of the Child and Adult Care Food Program (CACFP). _N_a_m_e_o_f C_e_n_te_r_______________ receives support from CACFP to serve those meals. CACFP gives more support if your household receives SNAP, TANF or FDPIR, or if your household income is less than or equal to the limits on this chart:

FEDERAL ELIGIBILITY INCOME CHART For 2022-2023

Household size

Yearly

Monthly

Weekly

1

$17,667

$1,473

$340

2

$23,803

$1,984

$458

3

$29,939

$2,495

$576

4

$36,075

$3,007

$694

5

$42,211

$3,518

$812

6

$48,347

$4,029

$ 930

7

$54,483

$4,541

$1,048

8

$60,619

$5,052

$1,166

Each additional person:

$6,136

$512

$118

Please fill out the attached CACFP Meal Benefit Income Eligibility form. It will help us find out how much support _N_a_m_e_of_C_e_n_te_r ______________________ receives. Please be sure to read the instructions carefully. Fill in all the information we request. We can only accept complete forms. Please return the forms to _In_s_e_rt_l_oc_a_ti_o_n_a_nd__ce_n_te_r_i_n_fo_rm__a_tio_n__he_r_e_________________________.

Thank you for taking the time to fill out the form. We hope your child enjoys CACFP meals!

In the operation of child nutrition programs, no person will be discriminated against because of race, color, national origin, sex, age, or disability. If you have questions or need help, please contact:_In_s_er_t _C_on_t_ac_t_N_a_m_e__________ at _P_ho_n_e_N_u_m_b_er______ or _E_m_a_il_A_d_d_re_s_s_o_f _C_on_t_ac_t_P_e_rs_o_n___.

Sincerely,

Printed Name Title

Page 1 of 4

Child and Adult Care Food Program | May 2022 | Arizona Department of Education | This institution is an equal opportunity provider.

Non-discrimination Statement (This explains what to do if you believe you have been treated unfairly): In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: , from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant's name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil

Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

1. mail:

U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW

Washington, D.C. 20250-9410; or

2.fax:

(833) 256-1665 or (202) 690-7442; or

3. email:

program.intake@

This institution is an equal opportunity provider.

Page 2 of 4

Child and Adult Care Food Program | May 2022 | Arizona Department of Education | This institution is an equal opportunity provider.

Programa de Comidas para Ni?os y Adultos Carta de Elegibilidad de Ingresos (Cuidado de ni?os No-Precio) FY 2023

Estimado Padre/Madre/Tutor:

_______________N_o_m__br_e_d_e_l _ce_n_t_ro_______________ ofrece alimentos saludables y bocadillos a los ni?os como parte de la participaci?n del Programa Alimenticio de Ni?os y Adultos (CACFP). ________________N_o_m_b_re_d_e_l c_e_n_tro________________ recibe apoyo de CACFP para servir esos alimentos. CACFP proporciona m?s apoyo si su unidad familiar recibe beneficios de programas como SNAP, TANF, o FDPIR, o si los ingresos de su hogar est?n dentro de los l?mites de esta gr?fica:

FEDERAL ELIGIBILITY INCOME CHART For 2022-2023

Household size

Yearly

Monthly

Weekly

1 2 3 4 5 6 7 8 Each additional person:

$17,667 $23,803 $29,939 $36,075 $42,211 $48,347 $54,483 $60,619

$6,136

$1,473 $1,984 $2,495 $3,007 $3,518 $4,029 $4,541 $5,052

$512

$340 $458 $576 $694 $812 $ 930 $1,048 $1,166 $118

Favor de completar el formulario de ingresos para beneficios de comidas para CACFP. Esto nos ayudar? a determinar cu?nto apoyo _________________N_o_m_b_re_d_e_l c_e_nt_ro_________________ recibir?. Favor de leer las instrucciones detalladamente y completar toda la informaci?n requerida. Solo formularios completos ser?n aceptados. Favor de regresar este formulario a _______________________________D_o_m_i_c_il_io__d_el_c_e_n_tr_o_______________________________.

Gracias por tomar el tiempo de completar este formulario. ?Esperamos que su ni?o disfrute de los alimentos de CACFP!

En la operaci?n de programas alimenticios, ninguna persona ser? discriminada basada en raza, color, origen nacional, sexo, edad, o discapacidad. Si tiene usted alguna pregunta o necesita asistencia, favor de contactar ____N_o_m_b_r_e_a_l _n_?_m_e_ro__de__te_l?_f_o_n_o_o_d_i_re_c_c_i?_n_d_e_c_o_r_re_o_e_l_ec_t_r?_n_i_co____.

Atentamente,

Nombre Titulo

Page 3 of 4

Child and Adult Care Food Program | May 2022 | Arizona Department of Education | This institution is an equal opportunity provider.

De conformidad con la Ley Federal de Derechos Civiles y los reglamentos y pol?ticas de derechos civiles del Departamento de Agricultura de los EE. UU. (USDA, por sus siglas en ingles), se proh?be que el USDA, sus agencias, oficinas, empleados e instituciones que participan o administran programas del USDA discriminen sobre la base de raza, color, nacionalidad, sexo, discapacidad, edad, o en realizados o financiados por el USDA.

Las personas con discapacidad que requieran medios alternativos de comunicaci?n para informarse del programa (por ejemplo, braille, letra grande, cinta de audio, lengua de signos americana, etc.) deben ponerse en contacto con el organismo (estatal o local) donde solicitaron sus prestaciones. Las personas sordas o con problemas de audici?n o deficiencias en el habla pueden ponerse en contacto con el USDA a trav?s del Federal Relay Service (servicio federal de transmisiones) en el (800) 877-8339. Adem?s, puede encontrar informaci?n del programa en otros idiomas adem?s del ingl?s.

Para presentar una queja por discriminaci?n contra el programa, llene el formulario de quejas por discriminaci?n contra el programa de USDA, (USDA Program Discrimination Complaint Form - AD-3027) disponible en l?nea en: (How to File a Complaint), y en cualquier oficina del USDA, o escriba una carta dirigida al USDA con toda la informaci?n solicitada en el formulario. Para solicitar una copia del formulario de queja, llame al (866) 632-9992. Env?e el formulario completo o carta al USDA por:

1. correo: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410

2. fax: (202)690-7442; o 3. email: program.intake@.

Esta instituci?n es un proveedor que ofrece igualdad de oportunidades.

Page 4 of 4

Child and Adult Care Food Program | May 2022 | Arizona Department of Education | This institution is an equal opportunity provider.

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