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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

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:

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
annual form updates
Annual Form Updates
  • Revision dates on forms
  • Always use most current form
distribute hsis and parent letter
Distribute HSIS and Parent Letter
  • Begin CACFP
  • Annual basis
  • New families

Collect HSIS back from parents


Name of Center


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





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



Calculating HSIS: Example 1

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


Calculating HSIS: Example 1




$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






$900 Every 2 Weeks

$500 + $400






reporting zero 0 income
Reporting Zero ($0) Income

Betsy Walker

Todd Walker

Ben Walker






$0 Income - FREE



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

Foster Child(ren)

Carol and Joseph Krantz


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






$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


Carol & Joseph



$1380 bi-wkly

part 3 all households
Part 3 – All Households

Karen Smith, 123 S. Center Street, Madison, WI 55555

Karen Smith



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

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


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


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!

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