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Get 2011-2012 CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Adult Care) Part 1 - Docs Alsde

S or anyone in the household receive SNAP (food stamps), SSI or Medicaid, provide a case number below. If these benefits are not received, skip to part 3. CASE NUMBER: Part 3. Total Household Gross Income You must tell us how much and how often B. Gross Income and how often it is received For example $200/week or $150/twice a month A. Name First and Last (List name of the participant s spouse and any dependent children) 1.Earnings from work before dedu.

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