Get Ny Doh-4161 2024-2025

The NY DOH-4161 form is essential for providers in the Child and Adult Care Food Program, helping determine eligibility for Tier I or Tier II reimbursement rates. This guide provides step-by-step instructions to complete the form online, ensuring users can navigate through each section effectively.

Follow the steps to complete the NY DOH-4161 form online.

1. Click the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by completing Part A, which collects personal and contact information, including the name of the day care, address, and contact details. Ensure accuracy, as this information is necessary for processing your application.
3. List all household members starting with yourself. For each person, provide their date of birth, relationship to you, and indicate if they are enrolled in care. This section is crucial for determining household size and eligibility.
4. If applicable, provide the SNAP, TANF, or FDPIR case number in Part A. This information allows for automatic Tier I eligibility verification.
5. Proceed to Part B, where you will list all household income for each member. Include all sources of income, such as wages, unemployment benefits, and any other income. Report how often each income is received to provide a clear picture of your financial situation.
6. In Part C, carefully read the certification statement and provide the last four digits of your Social Security number if you did not include a SNAP, TANF, or FDPIR case number. Ensure you sign and date this section, as it is required for the form to be processed.
7. Review all sections for completeness and accuracy. Once you have confirmed that all information is correct, save your changes.
8. You can download, print, or share the completed form from the online editor as needed.

Complete your NY DOH-4161 form online today to ensure timely processing and eligibility verification.