Determining Household Size-Income Statements (HSIS)

1. Determining Household Size-Income Statements (HSIS) Wisconsin Department of Public Instruction Child and Adult Care Food Program (CACFP) Child Care Institutions Outside of School Hours Care Centers

2. Household Size-Income Statements (HSIS) • Income eligibility forms are used to determine a child’s need category for monthly reimbursement claims • Need categories are: free, reduced or non-needy • Need categories have an impact on the amount of reimbursement received for each month a claim is submitted

3. Print copies to refer to throughout presentation: Guidance Memorandum #1C: http://fns.dpi.wi.gov/fns_centermemos • Household Size-Income Statement • Parent Letter • Household Size-Income Scale

4. Household Size-Income Statement & Parent Letter HSIS Parent Letter

5. Household Size-Income Statement & Parent Letter – Annual Updates Revision Date • Revised July each year • DPI will send new forms to your agency and post revisions on DPI website

6. Household Size-Income Scale

7. Collecting and Determining Household size-income statements

8. Determining Official • Completed and returned HSIS are ready to be determined and approved • Designate a “determining official” who is responsible for reviewing and approving all HSIS • Authorized Representative, Food Program Manager, Director, Owner

9. Determining Official After determining the eligibility, the determining official completes the bottom portion of the HSIS in the For Center Use Only box • Household size and total household income or categorical benefits • Eligibility determination (F,R, N) and • Initials and date of determination

10. Information on Child(ren) • The enrolled child’s name should be clearly written at the top of the HSIS • First and last name as it appears on the attendance records and enrollment forms • If there are siblings, parent may complete one HSIS listing all siblings’ names at the top of the form • If there are different last names, list the first and last name of each child Jim Cob, Jack Cob, Joe Smith ABC Child Development, LLC

11. Determining Household Size-Income Statements Part 1: households receiving assistance

12. Part 1: Households Receiving Assistance • Completed by households that receive one of the following types of assistance • Food Share Wisconsin (Food Stamps) • W-2 (Wisconsin Works) Cash Benefits • Trial Jobs; Community Service Jobs (CSJ); W-2 Transition (W-2 T); Caretaker of an Infant (CMC); At Risk Pregnancy (ARP) • W-2 Cash Benefits W-2 Child Care Assistance • W2 Child Care Assistance does NOT automatically qualify a household as free • FDPIR (Food Distribution Program on Indian Reservation) • These are the only assistance programs that automatically classify a child in the FREE category • Households not participating in one of these assistance programs will need to report income in Part 2

13. Part 1: Households Receiving Assistance • Food Share Wisconsin (Food Stamps) • 10 digit case number / 16 digit Quest card number • W-2 Cash Benefits • 10 digit case number • FDPIR • 9 digit case number 1 0 1 1 1 2 1 3 1 4

14. 1 0 1 1 1 2 1 3 1 4 • Households reporting a valid Food Share, W-2 Cash Benefits or FDPIR case number do NOT have to complete Part 2 (income and social security number)

15. Karen Smith, 123 S. Center Street, Madison, WI 55555 Karen Smith 10/17/12 1 0 1 1 1 2 1 3 1 4 MB 12/14/12

16. Determining Household Size-Income Statements Part 2: household members and income

17. Household Size and Income(Part 2) • Households that do not receive any assistance and who did not complete Part 1 are requested to complete Parts 2 and 3

18. Household Size and Income (Part 2) Karen smith 1 2 3 4 • The adult household member who signs the form MUST write their name and last 4 digits of their Social Security Number, or indicate by checking the box that he/she does not have one. • If the Social Security Number is missing and the box is not checked, the statement must be determined as Non-needy until the month proper information is obtained. • Households whose income is above the Income Eligibility Guidelines may write “NA” in Part 2. These statements are classified as Non-needy.

19. Household Size and Income Karen Smith 1 2 3 4 • All household members must be listed, including the children whose names are on the top of the HSIS • All income received in the month prior to completing the income statement must be reported Peter Smith Karen smith Joe Smith Jim Cob Jack Cob 500 Week 400 Bi-weekly 35 32 2 7 5 100 Month 100 Month

20. Computing Monthly Income • Convert incomes to yearly income when multiple pay periods or pay frequencies are reported: Multiply Weekly X 52 Multiply Every 2 weeks X 26 Multiply Twice a month X 24 Multiply Monthly X 12 • Compute household’s total yearly income • Compare total income to the Household Size-Income Scale to determine the need category

21. Karen Smith 1 2 3 4 Peter Smith Karen smith Joe Smith Jim Cob Jack Cob 35 32 2 7 5 500 Week 400 Bi-weekly 100 Month 100 Month • Peter - $500 x 52 = $26,000 • Karen - $400 x 26 = $10,400 • Jim & Jack -($100 + $100 = $200) $200 x 12 = $2,400 $38,800

22. Household Size-Income Scale Household size is 5; yearly income is $38,800

23. Household Size-Income Scale Household size is 5; yearly income is $38,800

24. REDUCED! 5 MB 10/04/12 $38,800 yr

25. Kathy hart 28 14 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

26. Household Size-Income Scale Household size is 5; every 2 week income is $900

27. FREE! 5 MB 10/21/12 $900 bi-wkly

28. Zero ($0) Income Betsy Walker 4 6 3 4 Betsy Walker Todd Walker Ben Walker 26 5 2 • Income:$0

29. $0 Income - FREE • Households that report “zero” ($0) income may be approved in the Free category for one year from the date of the determining official’s approval 3 MB 11/3/12 $0

30. Foster Child(ren) • Foster children are categorically eligible for free meals when the child’s care and placement is the responsibility of the State, or who is placed with a caretaker by a court of law • This eligibility does not extend to other non-foster child(ren) in the household • Households with foster and non-foster child(ren) may complete one HSIS and include the foster child(ren) as a household member. This may help the foster family’s non-foster child(ren) qualify for free or reduced prices meals based on household size and income

31. Foster Child(ren) Carol and Joseph Krantz Suzanne Winter, 123 S. Center Street, Madison, WI 55555 Suzanne Winter 9/11/12 MB 10/21/12

32. 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

33. Households with foster and non-foster children Suzanne Winter 8 6 2 9 900 Bi-weekly 460 Bi-weekly James winter Suzanne Winter Maria winter Carol Krantz Joseph Krantz 35 32 2 7 5 $900 + $460 = $1,360 Every 2 weeks

34. Household Size-Income Scale Household size is 5; every 2 week income is $1,360

35. Household Size-Income Scale Household size is 5; every 2 week income is $1,360

36. Households with foster and non-foster children Foster children (Carol and Joseph Krantz) = Free Non-foster child (Maria Winter) = Reduced 5 Carol & Joseph MB 10/21/12 Maria $1360 bi-wkly

37. Determining Household Size-Income Statements Part 3: All Households

38. Part 3 – All Households Karen Smith, 123 S. Center Street, Madison, WI 55555 Karen Smith 10/17/12 555-1234 Parent/Guardian Signature Required Parent/Guardian Signature DATE Required Income statements that are not signed and dated by an adult household member are INCOMPLETE applications and must be listed in the Non-Needy category

39. Determining Household Size-Income Statements reminders

40. Validity of HSIS • HSIS becomes effective the month in which the Determining Official initials and dates the form • HSIS is valid for a maximum of 12 months from the date of the determining official’s approval • Statement approved on June 15th will expire June 30th of following year

41. Dates on Income Statements • Collect new income statements from each household at the same time each year • Usually in September or October • This will reduce the chance that a child would accidentally be reported in the Free or Reduced category with an expired Household Size-Income Statement on file

42. Need Categories • Free • Households receiving assistance from qualifying program(s) • Monthly household income for household size is at or below the USDA income scale for FREE • Foster child • Reduced • Monthly household income for household size is within the USDA income scale for REDUCED • Non-Needy • Monthly household income for household size is above USDA income scale for reduced or adult household member writes “N/A” or “Does Not Qualify” on form • Adult household member refuses to complete the form • Adult household member fails to return the form • Form is incomplete (e.g. missing adult signature or date)

43. Income Statement Reminders • Income statement must be complete • If information is missing, contact the household • If you need to make a change to a statement, do not use white-out • With the exception of the signature and date, it is acceptable to obtain information over the phone to complete the HSIS • Must make a notation on the HSIS of how the information was obtained, from whom the information was received, the date it was received and your initials

44. Income Statement Reminders • Until the month the HSIS is correctly completed and determined, the child must be considered Non-needy • The Determining Official must complete the information in the “For Center Use Only” box including initials and date for the HSIS to become effective

45. What’s Next: Maintaining the Household Size-Income Record (HSIR) In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice).  Individuals who are hearing impaired 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.