Household size income statements hsis
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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. Print to refer to throughout presentation:. Household Size-Income Statement Parent Letter

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Household Size-Income Statements (HSIS)

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Household size income statements hsis

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


Print to refer to throughout presentation

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


Household size income statement hsis

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


Parent letter

Parent Letter

  • Provides information about CACFP eligibility and completing the HSIS

  • Income scale to help determine free or reduced eligibility


Household size income scale

Household Size-Income Scale


Annual form updates

Annual Form Updates

  • Revision dates on forms

  • Always use most current form


Collecting and determining hsis

Collecting and Determining HSIS


Distribute hsis and parent letter

Distribute HSIS and Parent Letter

  • Begin CACFP

  • Annual basis

  • New families

Collect HSIS back from parents


Household size income statements hsis

Name of Center

HSIS

Parent Letter

Authorized Representative signature


Determining official

Determining Official

  • Reviews/approves HSIS

    • Authorized Representative

    • Food Program Manager

    • Director

    • Owner

  • Completes HSIS For Center Use Only


Names of child ren

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


Part 1 assistance programs

Part 1: Assistance Programs

  • Automatically qualifies a child as FREE

    • SNAP (FoodShare Wisconsin)

    • W-2 Cash Benefits

    • FDPIR (Food Distribution Program on Indian Reservation)


Part 1 assistance programs1

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


Part 1 assistance programs2

Part 1: Assistance Programs

1 0 1 1 1 2 1 3 1 4


Household size income statements hsis

FREE!

MB MM/DD/YY


Household size income statements hsis

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


Part 2 all other households

Part 2: All Other Households

  • Households that do not complete Part 1 must complete Part 2


Part 2 all other households1

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


Part 2 all other households2

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


Determine total income amount

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


Household size income scale1

Household Size-Income Scale

  • Use to determine need category


Calculating hsis example 1

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


Household size income statements hsis

  • Calculating HSIS: Example 1

Household size is 5; yearly income is $38,800


Household size is 5 yearly income is 38 800

  • Calculating HSIS: Example 1

Household size is 5; yearly income is $38,800


Household size income statements hsis

  • Calculating HSIS: Example 1

REDUCED!

5

MB MM/DD/YY

$38,800 yr


Calculating hsis example 2

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


Household size is 5 every 2 week income is 900

Household Size-Income Scale

Household size is 5; every 2 week income is $900


Household size income statements hsis

FREE!

5

MB MM/DD/YY

$900/biweekly


Reporting zero 0 income

Reporting Zero ($0) Income

Betsy Walker

Todd Walker

Ben Walker

26

5

2

3

$0

$0 Income - FREE

MB MM/DD/YY


Household size income statements hsis

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


Household size income statements hsis

Foster Child(ren)

Carol and Joseph Krantz

MB MM/DD/YY


Households with foster and non foster children

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


Households with foster and non foster children1

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


Household size income scale2

Household Size-Income Scale

  • Family of 5 / $1,380 every two weeks

  • Above income guideline for free

  • Within income guidelines for reduced


Households with foster and non foster children2

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


Part 3 all households

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


Dates and review

dates and review


Need categories review

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)


Missing information

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


Hsis effective date

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


Hsis valid for 12 months

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


Collect new hsis annually

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!


What to do next

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


Thank you

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 [email protected]

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.


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