Little Panda's Child Development Center LLC Daycare Seville, FL, 32190. Child_care

Primary Hours of Care

Days of the Week in Care

Meals Typically Served While in Care

STEP 1: Complete the following table for all INFANTS and CHILDREN through age 18 that reside in the household, even if not related. (include child listed at top of form)

Attends this center?	Foster Child?	Migrant?	Homeless/Runaway?
Yes No	Yes No	Yes No	Yes No
Yes No	Yes No	Yes No	Yes No
Yes No	Yes No	Yes No	Yes No
Yes No	Yes No	Yes No	Yes No

STEP 2: Do any household members (children or adults) receive Food Assistance Program (FAP/SNAP) or Temporary Assistance for Needy Families (TANF) benefits?

If NO, go to STEP 3. If YES, enter one of the following case numbers, then go to STEP 5.

STEP 3: Children's Income Information (see reverse side for what types of income to report) (skip this step if you listed a case # in STEP 2).

Children's Income – sometimes children earn or receive income. Enter the total income received by all children listed in STEP 1, then check how often the income is received.

How often received? (check only one):

Weekly Bi-Weekly Twice a Month Monthly Annually

STEP 4: Household income and adult household member information (see reverse side for what types of income to report) (skip this step if you listed a case # in STEP 2)

Adult Household Members and Income – list all adult household members (age 19 and up) even if they do not receive income. For each adult, list the total gross income (before taxes & deductions) from each source in whole dollars only (no cents) and how often it is received (i.e., weekly, bi-weekly, twice a month, monthly, or annually). For an adult that does not receive income from any source, write “none” or “0.” If you enter “none” or “0” or leave any income fields blank, you are certifying that there is no income to report

Adult Household Member's Name (Last Name, First Name)	Earnings from Work ($ Amount / How often?)	Public Assistance/Child Support/Alimony ($ Amount / How often?)	Pensions/Retirement/All Other Income ($ Amount / How often?)
	Weekly Biweekly Monthly Twice a Month Annually	Weekly Biweekly Monthly Twice a Month Annually	Weekly Biweekly Monthly Twice a Month Annually
	Weekly Biweekly Monthly Twice a Month Annually	Weekly Biweekly Monthly Twice a Month Annually	Weekly Biweekly Monthly Twice a Month Annually

STEP 5: Contact information and adult signature.

By signing below, I am certifying (promising) that all information on this application is true and that all income is reported. I understand that this information is being given in connection with the receipt of federal funds and that institution officials may verify (check) the information. I am aware that if I purposely give false information, I may be prosecuted under applicable state and federal laws.

OPTIONAL: Child's ethnic and racial identities We are required to ask for information about your child’s ethnicity and race. This information is important and helps make sure that we are fully serving the community. Responding to this section is optional and does not affect your child’s eligibility for free or reduced-price meals.

Ethnicity
Hispanic or Latino Not Hispanic or Latino

Race
  American Indian or Alaskan Native
  Asian
  Black or African American
  Native Hawaiian or Other Pacific Islander
  White

CHILD CARE FOOD PROGRAM

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