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Confidential Income Statements - Centers

2021-2022 Confidential Income Statement - Centers and Family Day Care Home Providers (English and Spanish)

Letter to Household (English and Spanish)

2021-2022 Income Eligibility Guidelines (July 1, 2021 - June 30, 2022)

Important Notes

Reminder, sponsors have the flexibility concerning the effective date of certification for Program benefits. The date to be used to make this determination may be either the date the parent or guardian signed the Confidential Income Statement or the date on which the sponsor official signs the Confidential Income Statement to certify the eligibility of the participant. This flexibility applies only to eligibility determinations made through the application process of complete applications containing all required information at the time of submission. Sponsors must decide which date they will rely on as the effective date and apply this date to all Confidential Income Statements. However, if the date of parent or guardian signature is not within the month of certification or the immediately preceding month, the effective date must be the date of certification. For more information, refer to the ODE CNP Guidance on Income Eligibility Determinations and Duration – Reissued April 7, 2014 memo.

Download the fillable Letter to Household and insert the appropriate information in the gray fillable fields prior to distribution. The Letter to Household must be distributed with the CIS.

The CIS heading includes “Child Care Centers/Family Day Care Providers”. This dual-purpose form is the correct form for Child Care Centers, Head Start, and Outside-School-Hours Centers, including pricing and non-pricing programs.

The CIS “Sponsor Use Only” section is on the first page. Copy both sides of the CIS for distribution to parents.

Refer to the Child and Adult Care Food Program Policy and Procedure Manual, Chapter 3, Eligibility Determination for detailed instructions on the distribution and approval of CIS forms.