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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 these forms NOW:. Household Size-Income Statement Parent Letter Household Size-Income Scale

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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 these forms now
Print these forms NOW:
  • 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)
  • 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
parent letter
Parent Letter
  • Provides information about CACFP eligibility and completing the income statement
  • Income scale to help determine free or reduced eligibility
household size income scale
Household Size-Income Scale

July 1, 20XX to June 30, 20XX

annual updates
Annual Updates

INCOME STATEMENT

PARENT LETTER

INCOME SCALE

July 1, 20XX to June 30, 20XX

distribute hsis and parent letter
Distribute HSIS and Parent Letter
  • Begin CACFP
  • New families
  • Annual basis

Collect HSIS back from parents

slide8
Name of Center

HSIS

Parent Letter

Authorized Representative signature

determining official
Determining Official
  • Reviews, approves and determines HSIS
    • Authorized Representative
    • Food Program Manager
    • Director
    • Owner
  • Completes HSIS For Center Use Only
names of child ren
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
part 1 benefits
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)
part 1 benefits1
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

slide14
Randall Cobb

10/16/2014

FREE!

slide15
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 total household size and income
Part 2: Total Household Size and Income

Households that do not complete Part 1 must complete Part 2

part 2 total household size and income1
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
determine total income amount
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
calculating hsis example
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

slide20
Calculating HSIS: Example

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

July 1, 20XX to June 30, 20XX

slide22
Calculating HSIS: Example

REDUCED!

5

$38,800 yr

reporting zero 0 income
Reporting Zero ($0) Income

3

$0

Betsy Walker

Todd Walker

Ben Walker

$0 income is determined as FREE

households above income eligibility guidelines
Households above Income Eligibility Guidelines
  • Determined as Non-needy
  • Not required to turn in a HSIS

Above Guidelines

N/A

slide25
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

households with foster and non foster children
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
completing hsis with foster child ren
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

households with foster and non foster children1
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

kinship care is not foster care
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
part 3 all households
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

hsis is incomplete when
HSIS is Incomplete When…

These statements are NON-NEEDY until

complete information is obtained

obtain missing information
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

hsis effective date
HSIS Effective Date

CHOOSE ONE

  • Date of Determining Official Approval
  • Household Member Signature Date
  • Date Received by Center
slide35
Date of Determining Official Approval

Date DO reviews, determines

and approves the HSIS

MB 10/20/20XX

10/XX

household member signature date
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
date received by center
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
effective date of incomplete forms completed after initial submission
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

using date of determination for entire federal fiscal year
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)
hsis valid for 12 months
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

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
  • 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 program.intake@usda.gov.

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