determining household size-income statements (hsis) wisconsin department of public instruction child...
TRANSCRIPT
Determining Household Size-Income Statements (HSIS)
Wisconsin Department of Public InstructionChild and Adult Care Food Program (CACFP)
Child Care Institutions
Outside of School Hours Care Centers
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
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
Household Size-Income Statement & Parent Letter
HSIS Parent Letter
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
Household Size-Income Scale
COLLECTING AND DETERMINING HOUSEHOLD SIZE-INCOME STATEMENTS
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
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
Determining Official
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
PART 1: HOUSEHOLDS RECEIVING ASSISTANCE
Determining Household Size-Income Statements
Part 1: Households Receiving Assistance• Completed by households that receive one of the
following types of assistance1. Food Share Wisconsin (Food Stamps)
2. 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
3. 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
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
• 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)
1 0 1 1 1 2 1 3 1 4
MB 12/14/12
Karen Smith 10/17/12
Karen Smith, 123 S. Center Street, Madison, WI 55555
1 0 1 1 1 2 1 3 1 4
PART 2: HOUSEHOLD MEMBERS AND INCOME
Determining Household Size-Income Statements
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
• 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.
Karen smith 1 2 3 4
Household Size and Income (Part 2)
Household Size and Income
• 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 SmithKaren smithJoe SmithJim CobJack Cob
500 Week400 Bi-weekly
100 Month100 Month
Karen Smith 1 2 3 4
3532275
• Convert incomes to yearly income when multiple pay periods or pay frequencies are reported:
Multiply Weekly X 52Multiply Every 2 weeks X 26Multiply Twice a month X 24Multiply Monthly X 12
• Compute household’s total yearly income
• Compare total income to the Household Size-Income Scale to determine the need category
Computing Monthly Income
3532275
Peter SmithKaren smithJoe SmithJim CobJack Cob
500 Week400 Bi-weekly
100 Month100 Month
Karen Smith 1 2 3 4
• Peter - $500 x 52 = $26,000• Karen - $400 x 26 = $10,400• Jim & Jack -($100 + $100 = $200)
$200 x 12 = $2,400
$38,800
Household size is 5; yearly income is $38,800
Household Size-Income Scale
Household size is 5; yearly income is $38,800Household Size-Income Scale
REDUCED!
5MB 10/04/12
$38,800 yr
Kathy HartTom hartEdward hartWanda hartEmily will
500 Bi-weekly
400 Bi-weekly
Kathy hart 28 14
$900 Every 2 Weeks$500 + $400
3532275
Household size is 5; every 2 week income is $900
Household Size-Income Scale
FREE!
5MB 10/21/12
$900 bi-wkly
Zero ($0) Income
Betsy Walker 4 6 3 4
Betsy WalkerTodd WalkerBen Walker
2652
Income: $0
• 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
$0 Income - FREE
3
$0MB 11/3/12
• 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
Foster Child(ren)
Carol and Joseph Krantz
Foster Child(ren)
MB 10/21/12
Suzanne Winter, 123 S. Center Street, Madison, WI 55555
Suzanne Winter
9/11/12
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 children
James winterSuzanne WinterMaria winter
Carol KrantzJoseph Krantz
900 Bi-weekly
460 Bi-weekly
Suzanne Winter 8 6 2 9
3532275$900 + $460 = $1,360 Every 2 weeks
Household Size-Income ScaleHousehold size is 5; every 2 week income is $1,360
Household Size-Income ScaleHousehold size is 5; every 2 week income is $1,360
5MB 10/21/12
$1360 bi-wkly
Foster children (Carol and Joseph Krantz) = Free Non-foster child (Maria Winter) = Reduced
Carol & Joseph Maria
Households with foster and non-foster children
PART 3: ALL HOUSEHOLDS
Determining Household Size-Income Statements
Part 3 – All Households
Karen Smith 10/17/12
Karen Smith, 123 S. Center Street, Madison, WI 55555
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
REMINDERSDetermining Household Size-Income Statements
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
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
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)
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
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
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.