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 these forms NOW: • 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) • Required for children claimed free or reduced • Income form to determine financial need of child (free, reduced, non-needy) • Required for Household Size-Income Record

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

5. Household Size-Income Scale July 1, 20XX to June 30, 20XX

6. Annual Updates INCOME STATEMENT PARENT LETTER INCOME SCALE July 1, 20XX to June 30, 20XX

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

8. Name of Center HSIS Parent Letter Authorized Representative signature

9. Reviewing and Determining HSIS

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

11. Names of Child(ren) The Child and Adult Care Food Program HOUSEHOLD SIZE—INCOME STATEMENT (CHILD CARE COMPONENT) (FFY 2015, Rev. 7/14) An adult household member must complete and return to center. • Child’s first and last name • Siblings may be listed on one HSIS • If different last names, list the first and last name of each child

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

13. Part 1: Benefits 1 0 1 1 1 2 1 3 1 4 Wisconsin Shares – Child Care Subsidy is NOT a Wisconsin Works Cash Benefits program

14. Randall Cobb 10/16/2014 FREE!

15. 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

16. Part 2: Total Household Size and Income Households that do not complete Part 1 must complete Part 2

17. Part 2: Total Household Size and Income List all household members 500 Peter Smith Karen Smith Joe Smith Jim Cobb Jack Cobb X X 400 X 100 X 100 X • Report all gross income and • how often it is received

18. Determine Total Income Amount • Same Pay Frequency – add all reported income to get one total amount for that frequency • Multiple Pay Frequencies – convert each to annual amount and add to get one total amount for household • Do not round values resulting from conversion

19. Calculating HSIS: Example • Peter - $500 x 52 = $26,000 • Karen - $400 x 26 = $10,400 • Jim - $100 x 12 = $1,200 • Jack - $100 x 12 = $1,200 500 Peter Smith Karen Smith Joe Smith Jim Cobb Jack Cobb X X 400 X 100 X 100 X $38,800

20. Calculating HSIS: Example Household size is 5; Yearly income is $38,800 July 1, 20XX to June 30, 20XX

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

22. Calculating HSIS: Example REDUCED! 5 $38,800 yr

23. Reporting Zero ($0) Income 3 $0 Betsy Walker Todd Walker Ben Walker $0 income is determined as FREE

24. Households above Income Eligibility Guidelines • Determined as Non-needy • Not required to turn in a HSIS Above Guidelines N/A

25. 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 A child permanently placed in a home is considered a member of the household, not a foster child

26. Households with foster and non-foster children • Determine non-foster children based on benefits or household size and income • Can include foster child as a household member

27. Completing HSIS with Foster Child(ren) James winter Suzanne Winter Maria Winter Carol Krantz Joseph Krantz 900 480 $900 + $480 = $1,380 Every 2 weeks Family of 5 = Reduced

28. Households with Foster and Non-foster Children Foster children (Carol and Joseph Krantz) = Free Non-foster child (Maria Winter) = Reduced Carol & Joseph 5 Maria $1380 bi-wkly

29. Kinship Care is Not Foster Care • Kinship Care is when children reside with a relative rather than be placed in a foster home or other type of out-of-home placement • Must complete HSIS • Part 1 – qualifying assistance program OR • Part 2 – report income

30. Part 3: All Households Karen Smith 5/21/20XX 1 2 3 4 Signature Required Date Required Social Security Number Required when completing Part 2

31. HSIS is Incomplete When… These statements are NON-NEEDY until complete information is obtained

32. Obtain Missing Information • Return to or 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

33. HSIS Determination and Effective date

34. HSIS Effective Date CHOOSE ONE • Date of Determining Official Approval • Household Member Signature Date • Date Received by Center

35. Date of Determining Official Approval Date DO reviews, determines and approves the HSIS MB 10/20/20XX 10/XX

36. Household Member Signature Date • Date the Household Size-Income Statement was • signed and dated by the adult household member Karen Smith 4/16/20XX 1234 MB 5/21/20XX 4/XX • HSIS must be complete at time of submission for this method to apply • Agency may NEVER date the income statement for the parent/guardian

37. Date Received by Center • Date the Income Statement was submitted/receivedby agency • Required: date stamp upon receipt by the agency Apr 23, 20XX MB 6/2/20XX 4/XX • HSIS must be complete at time of submission for this method to apply

38. Effective Date of Incomplete Forms Completed AFTER Initial Submission • After ALL missing information is obtained • Determine the form free, reduced or non-needy Use Date of Determining Official Approval MB 12/20/20XX 12/XX

39. Using Date of Determination for Entire Federal Fiscal Year • Must choose one method for ALL complete HSIS • Indicate in online contract • Consistently apply to all HSIS for entire federal • fiscal year (October 1 – September 30)

40. dates and review

41. HSIS Valid for 12 Months • From Effective Date of Determination 10/20XX Example • Effective Date of Determination = October • HSIS will expire October 31st of following year Effective Date of Determination 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. Need Categories Review

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

45. 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.