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If all are foster children, skip to Section 6 |  |  |  | SNAP OR TANF CASE NUMBER Skip to Part 6 if you list a SNAP or TANF case number. At least one SNAP/TANF must be provided below. |  |\n|  |  |  | |  |  |  |  |  |\n|  |  |  | |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  |  |  | |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  |  |  | |  |  |  |  |  |\n\n 4.  Homeless, Migrant, or Runaway  \nHomeless  \nMigrant  \nRunaway  \nHead Start  \n______________________________________________________________________ __________________  \nSignature of Homeless Liason, Migrant Coordinator, or Head Start Director Date  \n\n| 5. | Total Household Gross Income (before deductions) You must tell us how much and how often. |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| NAMES\u003Cbr>(LIST ALL HOUSEHOLD MEMBERS WITH INCOME) |  | GROSS INCOME AND HOW OFTEN IT WAS RECEIVED (Example: $100/month; $100 /twice a month; $100/every other week; $100/week) |  |  |  |  |  |  |  |\n|  |  | Earnings From Work\u003Cbr>(Before Deductions) |  | Welfare, Child\u003Cbr>Support, Alimony |  | Pensions, Retirement, Social Security |  | Worker’s Comp. , Unemployment,\u003Cbr>SSI, etc. (All other income) |  |\n|  |  | Amount | How often? | Amount | How often? | Amount | How often? | Amount | How often? |\n| i . |  | $ |  | $ |  | $ |  | $ |  |\n| ii . |  | $ |  | $ |  | $ |  | $ |  |\n| iii . |  | $ |  | $ |  | $ |  | $ |  |\n| iv. |  | $ |  | $ |  | $ |  | $ |  |\n| v. |  | $ |  | $ |  | $ |  | $ |  |\n| 6. | Signature and Social Security Number (Adult must sign) |  |  |  |  |  |  |  |  |\n\nAisnliadstelt, htohuesahulimgenimnbgerthmefuosrsigmnuhtealapsoplliicstatthioen.laIfstSfeocutiroi5gitcofomhipsleoedheorrif zeSociarloSincomeecurity  x x x  -  x x  -    \nNumber or mark the “I do not have a Social Security Number ” box. Social Security Number  \nI do not have a Social Security Number.  \nI certify all information on this application is true and all income is reported. I understand the center will get federal funds based on the information I give. I understand the institution, Illinois State Board of Education, or Office of Inspector General, may verify this information on the application. Deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws.  \nDate Printed Name of Adult Household Member Signature of Adult Household Member  \n 7.  Contact Information (Optional)  \nWork Telephone Number (Include Area Code) Home Telephone Number (Include Area Code) Home Address (Number, Street, City, State, ZIP Code)  \n 8.  Children's Racial and Ethnic Identities (Optional)  \nMark one ethnic identity: Hispanic/Latino Not Hispanic/Latino  \nMark one or more racial identities:  \n Asian  Black or African American  Native Hawaiian or Other Pacific Islander  \n White  American Indian or Alaska Native  \n 9.  Optional – Sharing Information With All Kids Insurance Program  \nMay we share your information on this application with the All Kids Insurance Program , the complete health insurance program for every child in Illinois? If yes, do not sign below.  \n No, I do not want my information from this application shared with the All Kids Insurance Program.  \nDate:   Sign here:    \n\n| SFSP SPONSOR USE ONLY\u003Cbr>Eligibility Determination-Complete Sections A and B Below |  |\n| --- | --- |\n| SECTION A | Annual Income Conversion Weekly X 52 Every 2 Weeks X 26 Twice a Month X 24 Once a Month X 12 Convert income only if different\u003Cbr>frequencies of pay are reported. |\n| TOTAL\u003Cbr>INCOME $   Per:  Week  Every 2 Weeks  Twice a Mo","cbCaice8BYBbcoBC","https://ap.wps.com/l/cbCaice8BYBbcoBC","pdf",527736,"English","# All Household Members\n## Foster Child Information\n## Homeless, Migrant, or Runaway\n## Total Household Gross Income\n## Signature and Social Security Number\n## Contact Information (Optional)\n## Children’s Racial and Ethnic Identities (Optional)\n## Sharing Information With All Kids Insurance Program","[{\"question\":\"What information must be provided for all household members?\",\"answer\":\"Provide the names of all household members and the ages of children at the SFSP site. If applicable, identify foster children and complete the related boxes or parts.\"},{\"question\":\"How is total household gross income reported?\",\"answer\":\"List all household members with income, then enter gross income amounts and how often each payment was received (for example, monthly, twice a month, every other week, or weekly).\"},{\"question\":\"What are the adult signature and Social Security requirements?\",\"answer\":\"An adult household member must sign the application and provide a Social Security Number (or mark the box indicating that the adult does not have a Social Security Number).\"}]","HOUSEHOLD ELIGIBILITY APPLICATION FOR SUMMER FOOD SERVICE PROGRAM - Instructions | PDF",1791599114]