Get Ny Doh-4161 2020-2026

Filling out the NY DOH-4161 form is an essential step for day care home providers to determine eligibility for the Child and Adult Care Food Program. This guide will help you understand each section of the form and provide clear instructions for completing it online.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the NY DOH-4161 form online.
2. Begin filling out Part A by entering your name as the day care provider, along with your contact information including your street address, phone number, and mailing address if it differs from your street address.
3. List all individuals living in your household under the 'HOUSEHOLD' section. Start with your name, and include date of birth, relationship to you, and whether each person is enrolled in care.
4. Complete the 'SNAP, TANF, or FDPIR' section if applicable. Provide the appropriate case number if your household receives any of these benefits to qualify for Tier I eligibility.
5. Move to Part B to report household income. Enter the gross income for each household member listed, specifying the amounts as weekly, monthly, or yearly.
6. In Part C, read the certification statement carefully, then provide your Social Security number if you do not have a SNAP, TANF, or FDPIR case number. Ensure your information is accurate.
7. After completing the form, thoroughly review your entries for any errors. Once satisfied, save your changes and download or print the form as needed.
8. Finally, submit the completed form to your Sponsor as required.

Complete your NY DOH-4161 form online today for eligibility in the Child and Adult Care Food Program.