Form 1 Sample eligibility form

OMB 0970-0374; Expires: XX/XX/XXXX

1. Child’s name:

2. Child’s date of birth:

3. This child is eligible to participate in the program.  Yes  No

4. Type of eligibility interview conducted  In-person  Telephone

(If a telephone interview was conducted, please attach an explanation why the interview was not in-person)

5. Check the applicable category of eligibility for this child:

 SSI

 Homeless

 Foster Care

 Public assistance

 Income Eligible

 Between 100-130% of federal poverty guidelines
(no more than 35% of enrolled children may fall into this category)

6. Check the applicable determination for over-income children:

 Counted as part of 10% maximum for non-AI/AN programs

 Counted as part of the 49% maximum for AI/AN programs

7. What documentation was used to determine eligibility?

 Income Tax Form 1040	 Written statements from employers
 W-2	 Foster care reimbursement
 TANF documentation	 SSI documentation
 Pay stub or pay envelopes	 Other If Other, please explain: ____
 Unemployment

Documentation of no income:

8. Staff signature: Date of eligibility verification:

9. Staff name: Title: _____

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average .10 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.