Household Size-Income Statements (HSIS)

1. Household Size-Income Statements (HSIS) Child and Adult Care Food Program (CACFP) Wisconsin Department of Public Instruction Child Care Institutions Outside of School Hours Care Centers

2. Print to refer to throughout presentation: • Household Size-Income Statement • Parent Letter • Household Size-Income Scale Guidance Memorandum #1C: http://fns.dpi.wi.gov/fns_centermemos

3. Household Size-Income Statement (HSIS) • Income form to determine financial need of child (free, reduced, non-needy) • Help determine the amount of reimbursement your agency receives • Required for Household Size-Income Record

4. Parent Letter • Provides information about CACFP eligibility and completing the HSIS • Income scale to help determine free or reduced eligibility

5. Household Size-Income Scale

6. Annual Form Updates • Revision dates on forms • Always use most current form

7. Collecting and Determining HSIS

8. Distribute HSIS and Parent Letter • Begin CACFP • Annual basis • New families Collect HSIS back from parents

9. Name of Center HSIS Parent Letter Authorized Representative signature

10. Determining Official • Reviews/approves HSIS • Authorized Representative • Food Program Manager • Director • Owner • Completes HSIS For Center Use Only

11. Names of Child(ren) • Child’s full name at top of HSIS • First and last name as on attendance records and enrollment forms • Siblings may be listed on one HSIS • If different last names, list the first and last name of each child Jim Cob, Jack Cob, Joe Smith ABC Child Development, LLC

12. Part 1: Assistance Programs • Automatically qualifies a child as FREE • SNAP (FoodShare Wisconsin) • W-2 Cash Benefits • FDPIR (Food Distribution Program on Indian Reservation)

13. Part 1: Assistance Programs • W-2 Child Care Assistance is NOT a W-2 Cash Benefits program • W-2 Cash Benefits programs: • Trial jobs, community service, W-2 transition, caretaker of an infant, at-risk pregnancy

14. Part 1: Assistance Programs 1 0 1 1 1 2 1 3 1 4

15. FREE! MB MM/DD/YY

16. 1 0 1 1 1 2 1 3 1 4 • Households that complete Part 1 and report a valid case number do NOT have to complete Part 2

17. Part 2: All Other Households • Households that do not complete Part 1 must complete Part 2

18. Part 2: All Other Households Karen Smith • Adult household member must write name and last 4 digits of Social Security Number • Or indicate by checking the box that he/she does not have SS# • If this information is missing the form is incomplete and the statement is Non-Needy 1 2 3 4

19. Part 2: All Other Households • List all household members, including children • Report all income and how often it is received • Households above Income Eligibility Guidelines may write “NA” in Part 2, and are Non-needy

20. Determine Total Income Amount • Same Pay Frequency - add as is to get one total amount for household for that frequency • Multiple Pay Frequencies – convert each to annual amount and add to get one total amount for household • Do not round off values resulting from conversion

21. Household Size-Income Scale • Use to determine need category

22. Calculating HSIS: Example 1 • Peter - $500 x 52 = $26,000 • Karen - $400 x 26 = $10,400 • Jim - $100 x 12 = $1200 • Jack - $100 x 12 = $1200 $38,800

23. Calculating HSIS: Example 1 Household size is 5; yearly income is $38,800

24. Calculating HSIS: Example 1 Household size is 5; yearly income is $38,800

25. Calculating HSIS: Example 1 REDUCED! 5 MB MM/DD/YY $38,800 yr

26. Calculating HSIS: Example 2 Kathy Hart Tom Hart Edward Hart Wanda Hart Emily Will 500 Bi-weekly 400 Bi-weekly 35 32 2 7 5 $900 Every 2 Weeks $500 + $400

27. Household Size-Income Scale Household size is 5; every 2 week income is $900

28. FREE! 5 MB MM/DD/YY $900/biweekly

29. Reporting Zero ($0) Income Betsy Walker Todd Walker Ben Walker 26 5 2 3 $0 $0 Income - FREE MB MM/DD/YY

30. Foster Child(ren) • Foster children are eligible for free meals when the child’s care and placement is responsibility of the State or the child is placed with a caretaker by a court of law

31. Foster Child(ren) Carol and Joseph Krantz MB MM/DD/YY

32. 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

33. Households with foster andnon-foster children Suzanne Winter 8 6 2 9 900 Bi-weekly 480 Bi-weekly James winter Suzanne Winter Maria Winter Carol Krantz Joseph Krantz 35 32 2 7 5 $900 + $480 = $1,380 Every 2 weeks

34. Household Size-Income Scale • Family of 5 / $1,380 every two weeks • Above income guideline for free • Within income guidelines for reduced

35. Households with foster andnon-foster children Foster children (Carol and Joseph Krantz) = Free Non-foster child (Maria Winter) = Reduced 5 Carol & Joseph MB MM/DD/YY Maria $1380 bi-wkly

36. Part 3 – All Households Karen Smith, 123 S. Center Street, Madison, WI 55555 Karen Smith 10/17/YY 555-1234 ParentSignature Required Parent Signature Date Required Income statements not signed and dated by adult household member are INCOMPLETE and must be determined as NON-NEEDY

37. dates and review

38. Need Categories Review • Free • Receiving assistance from qualifying program • Income at or below USDA guideline for FREE • Foster child • Reduced • Income within USDA guideline for REDUCED • Non-Needy • Income above USDA guideline for reduced • “N/A” or “Does Not Qualify” written on form • Parent refuses to complete/ does not turn in • Form is incomplete (e.g. missing adult signature or date)

39. Missing Information? • Missing information • Return to parent • Contact parent • Get info over the phone (not parent signature/date) • Record missing information • Who provided info • Date • Your initials • Any changes • Cross off invalid info • Do not use white out HSIS is Non-Needy until it is complete

40. HSIS Effective Date • Month Determining Official initials and dates form • Dated 10/21 is valid for all of October • Cannot back date to prior months MB 10/21/YY FREE

41. HSIS Valid for 12 Months • Valid for 12 months from date the determining official initials and dates form • Approved October 21st will expire October 31st of following year Form Approved Form Expires

42. Collect New HSIS Annually • Collect new statements from all families • Same time each year • Prevent incorrectly reporting a child as Free or Reduced with an expired HSIS on file • Do this in October!

43. What to do Next • What to do NOW: Distribute HSIS and Parent Letter to parents and collect back • Watch Household Size-Income Record (HSIR) webcast

44. Thank you! The U.S Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department.  (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov. Individuals who are deaf, hard of hearing 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.