Form 1 Sample eligibility form

Head Start Eligibility Verification Form
1. Child’s name: ___________________________________________________
2. Child’s date of birth: ______________________________________________
3. Is this child eligible to participate in the program?

Yes

No

4. Type of eligibility interview conducted:

In-person

Telephone

5. Indicate the applicable eligibility criterion for this child:
Homeless
Foster care
Public assistance (TANF & SSI)
Income at or below 100% FPL

Other (up to 10% may fall into this
category, up to 49% for AI/AN
programs)*
Income between 100-130% FPL (up
to 35% may fall into this category)**

*45 CFR 1302.12(c)(2) specifies that a program may enroll a child who would benefit from services but
does not meet other eligibility requirements provided that these participants only make up to 10 percent of
a program’s enrollment or 49 percent in the case of AI/AN programs as described in 45 CFR 1302.12(e).
**45 CFR 1302.12(d) specifies that a program may enroll an additional 35 percent of participants whose
families do not meet any other eligibility criterion and whose incomes are below 130 percent of the
poverty line.

6. What documentation was used to determine eligibility and is included as part of the
eligibility determination record?
Income Tax Form 1040

Unemployment documentation

W-2

Written statement from employers

TANF documentation

Foster care reimbursement

SSI documentation

Other, please describe:

Pay stub or pay envelopes

____________________________

7. Staff signature: _______________________

Date: _____________________

8. Staff name: __________________________

Title: ______________________

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