ࡱ> c 5 bjbjԚ 7Z\Z\R~~ 8B l d /f""(""":$:$:$F/H/H/H/H/H/H/$-13l/:$:$:$:$:$l/""H/&&&:$""F/&:$F/&&V,@-"5s%R:- 2//0/F-xg5V%lg5-g5-t:$:$&:$:$:$:$:$l/l/&:$:$:$/:$:$:$:$g5:$:$:$:$:$:$:$:$:$~> : California Department of Education Child and Adult Care Food Program Nutrition Services Division NSD 3101 / CACFP 29 (REV. 1/2015) Page  PAGE 1 of  NUMPAGES 5 MEAL BENEFIT FORM FOR CHILDREN PROGRAM YEAR __17/18____ Name of Child Care Center:Ƶ Child Development Center  Please read the instructions. If you need help completing this form call:619-660-4660 Complete, sign, and return form to:Natalija Worrell, CDC Center Technician  1. CHILD INFORMATION (List names of all children enrolled for care)Check the box if the child is a foster child (the legal responsibility of a welfare agency or court). Last First M.I.If all children are foster children, go to #4 and sign this form.   FORMCHECKBOX    FORMCHECKBOX    FORMCHECKBOX    FORMCHECKBOX  2. BENEFITS (If you are receiving CalFresh, CalWorks, FDPIR, or Kin-GAP benefits for your child, list the case number and do not complete #3. Go to #4.) CalFresh Case Number: CalWorks Case Number: FDPIR Case Number: Kin-GAP Number: 3. ALL HOUSEHOLD MEMBERS (Complete this section if you did not complete #2. List all household members. List all income. Go to #4.)NAMESGROSS INCOME and how often it was received (e.g. weekly, every 2 weeks, twice a month, monthly, or annually) NAMES OF ALL HOUSEHOLD MEMBERS (INCLUDE THE CHILDREN LISTED ABOVE) EARNINGS FROM WORK BEFORE DEDUCTIONS CHILD SUPPORT, ALIMONY PAYMENTS FROM PENSIONS, RETIREMENT, SOCIAL SECURITY EARNINGS FROM ANY OTHER INCOME  $ $ $ $  $ $ $ $  $ $ $ $  $ $ $ $  $ $ $ $  $ $ $ $  $ $ $ $  $ $ $ $ 4. LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (SSN) AND SIGNATURE (PENALTIES FOR MISREPRESENTATION: I Certify that all of the above information is true and correct and that the CalFresh, CalWORKS, FDPIR, Kin-GAP, or other eligible program case number is current, correct, or that all income is reported. I understand that this information is being given for the receipt of federal funds; that agency officials may verify the information on the Meal Benefit Form and that the deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws.)  Printed Name: Last Four Digits of SSN:  FORMCHECKBOX  Check here if no SSN Signature of Adult: Date: PRIVACY ACT STATEMENT The Richard B. Russel National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve the participant for free or reduced-price meals. You must include the last four digits of the Social Security Number of the adult household member who signs the application. The last four digits of the Social Security Number are not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP, or CalFresh), Temporary Assistance for Needy Families (TANF, or CalWORKS) Program, Kinship Guardian Assistance Payment Program (Kin-GAP), or Food Distribution Program on Indian Reservations (FDPIR) case number for the participant or other (FDPIR) identifier or when you indicate that the adult household member signing the application does not have a Social Security Number. We will use your information to determine if the participant is eligible for free or reduced-price meals, and for the administration and enforcement of the program. The last four digits of the SSN may be used to identify the household member in verifying the correctness of the information stated on the form. This may include program reviews, audits and investigations, and may include contacting employers to determine income, contacting a CalFresh, CalWORKs, FDPIR, or Kin-GAP office to determine current certification for CalFresh, CalWORKs, FDPIR, or Kin-GAP benefits, contacting the state employment security office to determine the amount of benefits received, and checking the documentation produced by the household member to prove the amount of income received. These efforts may result in a loss or reduction of benefits, administrative claims, or legal actions if incorrect information is reported. The last four digits of the SSN may also be disclosed to programs as authorized under the NSLA and the Child Nutrition Act, the Comptroller General of the United States, and law enforcement officials for the purpose of investigating violations of certain federal, state, and local education, and health and nutrition programs. 5. RACIAL/ETHNIC IDENTITY You are not required to answer these questions. If you choose to do so, please mark one or more of the following racial identities: FORMCHECKBOX  American Indian or Alaskan Native FORMCHECKBOX  Asian FORMCHECKBOX  Black or African American  FORMCHECKBOX  Native Hawaiian or Other Pacific Islander FORMCHECKBOX  WhitePlease mark one of the following ethnic identities:  FORMCHECKBOX  Hispanic or Latino FORMCHECKBOX  Not Hispanic or Latino     California Department of Education Child and Adult Care Food Program Nutrition Services Division NSD 3101 / CACFP 29 (REV. 1/2015) Page  PAGE 2 of  NUMPAGES 2 n t ! & ' - . / 0 4 5 @ A B C D E c ꦎsꦎs^M;#hUh^5CJOJQJ^JaJ hLv#h!+CJOJQJ^JaJ)h!+5B*CJOJQJ\^JaJph@@@4h!+5B*CJOJQJ\^JaJmHnHph@@@u/h$h!+5B*CJOJQJ\^JaJph@@@8jh$h!+5B*CJOJQJU\^JaJph@@@)h$h!+B*CJOJQJ^JaJphYYY#h!+B*CJOJQJ^JaJph@@@)h$h!+B*CJOJQJ^JaJph@@@D E d ~   v_kd$$Ifl0>R&  t(644 lapyt$ $If^gdx^$a$gdU $R&>>]>^>gd!+ c d e m r t u v x y } ~      ޽~q`O`A`:`O`A h$h%hIRCJOJQJ^JaJ h$h_OCJOJQJ^JaJ h$h%CJOJQJ^JaJh%h^OJQJ^J#hUhlU5CJOJQJ^JaJhIR>*CJOJQJ^JaJh"hA>*CJOJQJ^JaJh>*CJOJQJ^JaJ#hUh^>*CJOJQJ^JaJhQ 5CJOJQJ^JaJ#hUh^5CJOJQJ^JaJhU5CJOJQJ^JaJ  ! E n $If^gdx^_kdz$$Ifl0>R&P t(644 lapyt$$If  C D E m n o p s    } ~ 輪ujcUjucjh$huU h$hujh$huU h$huCJOJQJ^JaJ#h$hN5CJOJQJ^JaJ#h$h5CJOJQJ^JaJ#h$h%5CJOJQJ^JaJh%h^OJQJ^JhIRCJOJQJ^JaJ h$h_OCJOJQJ^JaJ h$h% h$h%CJOJQJ^JaJn o p  $If $If^gdx^akd$$Ifl^0>@ R&  t(644 lapyt$   ~ xrir $IfgdN$Ifkdr$$Ifl0>4R& t0(644 lapyt$ iccZZ $IfgdT$Ifkd-$$Ifl0>4R&  t0(644 lapyt$ vpppp$Ifkdl$$Ifl0>4R& t0(644 lapyt$              & 侷ݩ﷾݊ygVgVO h$h h$hCJOJQJ^JaJ#h$h5CJOJQJ^JaJ hz>h%CJOJQJ^JaJj=h$h]`U h$hNCJOJQJ^JaJj&h$h]`U h$h% h$h%CJOJQJ^JaJjh$h]`U h$h]`jh$h]`U h$h]`CJOJQJ^JaJ  vpppp$Ifkd$$Ifl0>4R& t0(644 lapyt$      vpppp$Ifkd$$Ifl0>4R& t0(644 lapyt$   & vtgg $If^gdx^kd$$Ifl0>4R& t0(644 lapyt$ $IfnkdT$$Ifl>R&( t0(644 lap yt$   %CJ$޵׫p^L#h$h}Q5CJOJQJ^JaJ#h$hl5CJOJQJ^JaJ h$h}QCJOJQJ^JaJ h$hEY h$hEYCJOJQJ^JaJ#h$hEY5CJOJQJ^JaJhNOJQJ^J h$h_OCJOJQJ^JaJ h$h@$CJOJQJ^JaJ h$h_O h$h_OCJOJQJ^JaJ h$h@$CJOJQJ^JaJ $Ifskd$$Ifl4%>R&( t0(644 laf4p yt$ $Ifskd$$Ifl4%>R&( t0(644 laf4p yt$ $Ifskd' $$Ifl4%>R&( t0(644 laf4p yt$   %|| $If^gdx^skd $$Ifl4">R&( t0(644 laf4p yt$$IfnkdI $$Ifl>R&( t0(644 lap yt$%IJopg[OOIOIO$If $$Ifa$gd$ $$Ifa$gd$kd $$Ifl0> R& ^  t0(644 lapyt$$%HIJnop}~ʹ۪ʙo^^^^^^^ h$hIVCJOJQJ^JaJ h$huCJOJQJ^JaJ h$hl#h$hl5CJOJQJ^JaJ h$hEYCJOJQJ^JaJhNY5CJOJQJ^JaJ h$hlCJOJQJ^JaJ h$h}QCJOJQJ^JaJ#h$h}Q5CJOJQJ^JaJ#h$hEY5CJOJQJ^JaJ$$If $$Ifa$gd$.((($Ifkd $$IflVr> HR& TT t0(644 lap2yt$$If0***$Ifkd $$Iflr> HR& TT t0(644 lap2yt$$If0***$Ifkdq $$Iflr> HR& TT t0(644 lap2yt$     "#%&()*+,./1245789:;=>@ACDFGJLMOPRSUVƵ͵͵͵ͮ h$h`#* h$h`#*CJOJQJ^JaJ h$hl h$hIVCJOJQJ^JaJ h$hlCJOJQJ^JaJ h$hEYCJOJQJ^JaJ@ $If    0***$IfkdJ$$Iflr> HR& TT t0(644 lap2yt$$If0***$Ifkd#$$Iflr> HR& TT t0(644 lap2yt$ "#%&($If()*+,0***$Ifkd$$Iflr> HR& TT t0(644 lap2yt$,./12457$If789:;0***$Ifkd$$Iflr> HR& TT t0(644 lap2yt$;=>@ACDF$IfFGHIJ0***$Ifkd$$Iflr> HR& TT t0(644 lap2yt$JLMOPRSU$IfUVW0.! $If^gdx^kd$$Iflr> HR& TT t0(644 lap2yt$VW,-;<=?TUikqrs䯞nc\Ncnjh$h]`U h$h]`jh$h]`U h$h_OCJOJQJ^JaJ h$hU h$h`#* h$h tCJOJQJ^JaJ h$hUCJOJQJ^JaJ h$h`#*CJOJQJ^JaJ#h$h:5CJOJQJ^JaJ#h$hU5CJOJQJ^JaJ#h$h`#*5CJOJQJ^JaJh`#*OJQJ^J}nkd`$$Ifl>R&( t0(644 lap yt$ $If^gdx^$IfT} $Ifgd$$Ifnkd$$Ifl>R&( t0(644 lap yt$TUVjkq$Ifnkd $$Ifl>R&( t0(644 lap yt$qrsxvffYYYL >>]>^>gdA >>]>^>gd)>>d]>^>gdAkd$$Ifl0>^R&  t0(644 lapyt$s,-.ouqeVE3E#h$hQ 5CJOJQJ^JaJ h$hQ CJOJQJ^JaJhQ h(S CJOJQJ^Jht#CJOJQJ^JhQ hQ CJOJQJ^JhQ h(S 5CJOJQJ^JhQ 5CJOJQJ^JhQ hQ 5CJOJQJ^Jh(S OJQJ^JhAOJQJ^J h)h)CJOJQJ^JaJ/ht#h:5B*CJOJQJ\^JaJph)hA5B*CJOJQJ\^JaJph-.spkd2$$IflM>R&( t0(644 lap yt$ $IfgdT^gdQ >^>gdx^ =>?MNOWXy۶zf۶'jph$hQ OJQJU^J'jh$hQ OJQJU^J'jh$hQ OJQJU^J'jEh$hQ OJQJU^J h$hQ CJOJQJ^JaJ'jh$hQ OJQJU^J!jh$hQ OJQJU^J h$hQ h$hQ OJQJ^J$=>W^UUU $IfgdTkd-$$IflF>R&f   t0(6    44 lapyt$WX^U $IfgdTkd$$IflF>R&f   t0(6    44 lapyt$ypȷϣϷϏȇzrnrnrnrnY)h$hLv#B*CJOJQJ^JaJph@@@hzjhzUh%hlYOJQJ^Jh *hlY5'jh$hQ OJQJU^J'jh$hQ OJQJU^J!jh$hQ OJQJU^J h$hQ h$hQ OJQJ^J h$hQ CJOJQJ^JaJ#h$hQ 5CJOJQJ^JaJ $IfgdTpkd$$Ifll>R&( t0(644 lap yt$vq`[Y[Y[Y[gd`#* R&>]^>gdNgdkd$$Ifl0>R&4 t0(644 lapyt$ 2 3 4 5  R&>]^>gdN $R&>>]>^>gd$ $R&>>]>^>gd*p0MU\bce      իիoR:R/h$hRG5B*CJOJQJ\^JaJph@@@8jh$hRG5B*CJOJQJU\^JaJph@@@)h$hRGB*CJOJQJ^JaJphYYY)h$hLv#B*CJOJQJ^JaJphYYY#hB*CJOJQJ^JaJph@@@)h$h$B*CJOJQJ^JaJph@@@)h$hRGB*CJOJQJ^JaJph@@@)h$hLv#B*CJOJQJ^JaJph@@@)h$h*B*CJOJQJ^JaJph@@@   " # . / 0 1 2 3 4 5 ȳțȊuh%hlYOJQJ^JhzhT hLv#hLv#CJOJQJ^JaJ/h$hRG5B*CJOJQJ\^JaJph@@@)h$hRGB*CJOJQJ^JaJph@@@8jh$hRG5B*CJOJQJU\^JaJph@@@4h"hA5B*CJOJQJ\^JaJmHnHph@@@u 5 01h:p!+/ =!"#$% x$$If!vh#v #v:V l t(65 5/ apyt$x$$If!vh#vP#v:V l t(65P5/ apyt$|$$If!vh#v #v:V l^ t(65 5/ apyt$$$If!vh#v#v:V l t0(655/  / apyt$$$If!vh#v#v:V l  t0(655/ apyt$tDeCheck4$$If!vh#v#v:V l t0(655apyt$tDeCheck4$$If!vh#v#v:V l t0(655apyt$tDeCheck4$$If!vh#v#v:V l t0(655apyt$tDeCheck4$$If!vh#v#v:V l t0(655apyt$$$If!vh#v(:V l t0(65(/  / ap yt$$$If!vh#v(:V l4% t0(65(/ af4p yt$$$If!vh#v(:V l4% t0(65(af4p yt$$$If!vh#v(:V l4% t0(65(af4p yt$$$If!vh#v(:V l4" t0(65(af4p yt$$$If!vh#v(:V l t0(65(/  / ap yt$$$If!vh#v #v^:V l  t0(65 5^/ apyt$$$If!vh#v #vT#v#v:V lV t0(65 5T55ap2yt$$$If!vh#v #vT#v#v:V l t0(65 5T55ap2yt$$$If!vh#v #vT#v#v:V l t0(65 5T55ap2yt$$$If!vh#v #vT#v#v:V l t0(65 5T55ap2yt$$$If!vh#v #vT#v#v:V l t0(65 5T55ap2yt$$$If!vh#v #vT#v#v:V l t0(65 5T55ap2yt$$$If!vh#v #vT#v#v:V l t0(65 5T55ap2yt$$$If!vh#v #vT#v#v:V l t0(65 5T55ap2yt$$$If!vh#v #vT#v#v:V l t0(65 5T55ap2yt$$$If!vh#v(:V l t0(65(/  / ap yt$$$If!vh#v(:V l t0(65(/ ap yt$tDeCheck4$$If!vh#v(:V l t0(65(ap yt$$$If!vh#v #v :V l t0(65 5 apyt$$$If!vh#v(:V lM t0(6,5(/ ap yt$tDeCheck4tDeCheck4tDeCheck4$$If!vh#v#vf #v :V l t0(6,55f 5 / apyt$tDeCheck4tDeCheck4!$$If!vh#v#vf #v :V l t0(6,55f 5 / / / / / / / apyt$$$If!vh#v(:V ll t0(6,5(/ ap yt$tDeCheck4tDeCheck4$$If!vh#v#v4:V l t0(6,554/ apyt$ )s666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ OJPJQJ_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH vv  5 Heading 1,$d<<\]@&^Z`a$5CJOJPJQJ\^JaJvv  5 Heading 2,$d<<\]@&^Z`a$5CJOJPJQJ\^JaJnn  5 Heading 3$$d\]@&^Z`a$5CJOJPJQJ\^JaJpp  5 Heading 4%$d<<@&]^`a$5CJOJPJQJ\^JaJpp  5 Heading 5%$d<<@&]^`a$5CJOJPJQJ\^JaJ``  5 Heading 6$d@&]^5CJOJPJQJ\^JaJnn  5 Heading 7$$d\]@&^Z`a$5CJOJPJQJ\^JaJDA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List jj ^ Table Grid7:V0@@ % List Paragraph ^m$HH S!0 Balloon TextCJOJQJ^JaJN/!N S!0Balloon Text CharCJOJQJ^JaJ4@24 `#*0Header H$.A. `#*0 Header Char4 R4 `#*0Footer H$.a. `#*0 Footer Chardord ]`Default1$7$8$H$-B*CJOJPJQJ_HaJmH phsH tH 6U 6 t#0 Hyperlink >*B*phR/R  5Heading 1 Char5CJOJPJQJ\^JaJR/R  5Heading 2 Char5CJOJPJQJ\^JaJR/R  5Heading 3 Char5CJOJPJQJ\^JaJR/R  5Heading 4 Char5CJOJPJQJ\^JaJR/R  5Heading 5 Char5CJOJPJQJ\^JaJR/R  5Heading 6 Char5CJOJPJQJ\^JaJR/R  5Heading 7 Char5CJOJPJQJ\^JaJH>H ! 5Title a$5CJOJPJQJ\^JaJJ/J 5 Title Char5CJOJPJQJ\^JaJlC"l # 5Body Text Indent"x^`a$CJOJPJQJ^JaJZ/1Z " 5Body Text Indent CharCJOJPJQJ^JaJpRBp % 5Body Text Indent 2$<$^$`qa$CJOJPJQJ^JaJ^/Q^ $ 5Body Text Indent 2 CharCJOJPJQJ^JaJTb lY Block TextN&;`0p@ :P !$`'0*1$]I^a$CJOJPJQJ^JaJZ^rZ 9a0 Normal (Web)'dd[$\$CJOJPJQJ^JaJ*W * 9a`Strong5\PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VvnB`2ǃ,!"E3p#9GQd; H xuv 0F[,F᚜K sO'3w #vfSVbsؠyX p5veuw 1z@ l,i!b I jZ2|9L$Z15xl.(zm${d:\@'23œln$^-@^i?D&|#td!6lġB"&63yy@t!HjpU*yeXry3~{s:FXI O5Y[Y!}S˪.7bd|n]671. tn/w/+[t6}PsںsL. J;̊iN $AI)t2 Lmx:(}\-i*xQCJuWl'QyI@ھ m2DBAR4 w¢naQ`ԲɁ W=0#xBdT/.3-F>bYL%׭˓KK 6HhfPQ=h)GBms]_Ԡ'CZѨys v@c])h7Jهic?FS.NP$ e&\Ӏ+I "'%QÕ@c![paAV.9Hd<ӮHVX*%A{Yr Aբ pxSL9":3U5U NC(p%u@;[d`4)]t#9M4W=P5*f̰lk<_X-C wT%Ժ}B% Y,] A̠&oʰŨ; \lc`|,bUvPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!R%theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] 5 QQQQQTc  $Vsyp 5 &-:?ADHI n     (,7;FJUTqW5  !"#$%'()*+,./0123456789;<=>@BCEFG&-/4@B, < >N5!G G G G G G G G G G G G 29;@LNT!T # @H 0(  0(  B S  ?r}<DFN    !36d}36EtyEmpp}~, = ><BJMUcdd"16L#2t6#n\DYhxPx2p !t!^!`to()^`.L^`L.m m ^m `.==^=`. L ^ `L.^`.^`.}L}^}`L.^`o(.^`.pL^p`L.@ ^@ `.^`.L^`L.^`.^`.PL^P`L.t^`to(.^`o()L^`L.  ^ `.  ^ `.~L~^~`L.NN^N`.^`.L^`L.6#nhxPxL#                 T       W ?/ `(u? Q (S NTTDe A!t#Lv#@$%He%{*`#*!+D/+ 5z>"hA C^DfE`K_O>STIVNYlY:tYY[_Z`]` $i t v!ew0{$^:AasEY_$/+RGS!lNL *Mi|` I}QR9aIRAK\U)x^](lUz_S~l*&@yyyy5@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial7.@Calibri5. .[`)TahomaA$BCambria Math"qh;W;W6#'D 'D '!r0KQHP  $P^2!xx LMeal Benefit Form - Child and Adult Care Food Program (CA Dept of Education)CForm 3101 Child care center application for children's eligibility.Patty AthertonNatalija Worrell   Oh+'0 <T`t     PMeal Benefit Form - Child and Adult Care Food Program (CA Dept of Education)DForm 3101 Child care center application for children's eligibility.Patty Atherton Normal.dotmNatalija Worrell2Microsoft Office Word@F#@@ⷀs@ⷀsD՜.+,0 px   iLaurie Pennings8California Department of Education, Nutrition Services'  MMeal Benefit Form - Child and Adult Care Food Program (CA Dept of Education) Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJLMNOPQRSTUVWXY[\]^_`abcdefghijklmnopqrstvwxyz{|~Root Entry F5sData KE1TableZ5WordDocument 7SummaryInformation(uDocumentSummaryInformation8}MsoDataStore+s5sIAZVERWC4ZAQ==2+s5sItem  PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q