child and adult care food program · pdf filechild and adult care food program ... [name,...

CHILD AND ADULT CARE FOOD PROGRAM

May 2011 CACFP Meal Benefit Income Eligibility Form Instructions for Centers and Sponsors

of 1 - Mien

DUQV FAI MAIV DUQV NYANC HOPV NYAANH NYEI FORMH

Njaaux taux Njaaux taux uiz fu’jueiv caux domh mienh nyei gorn, Nzie nyei gorn caux hmuangv doic tengx goux mangc nyei mienh

Formh se gan naaiv daapc sou daaih: Biauv zong mienh caux goux mangc nyei mienh oix zuqc duqv zipv naaiv deix fienx:

• Fienx bun biauv zong mienh: Fu’jueiv goux mangc nyei gorn (Child Day Care) caux Tier II gong-ziouv caux Domh Mienh goux mangc nyei gorn (Adult Day Care).

• Bun Tier I caux Hmuangv doic goux nyei mangc nyei ziouv • Duqv Tengx fai maiv duqv nyei nyanc hopv Formh: Fu’jueiv goux mang nyei gorn caux Domh

Mienh goux mangc nyei gorn (maaih jienv njaaux nyei leiz) Tong Hiuv: Saengv nyei hungh jaa maiv haapc dingc oix zuqc longc naaiv zeiv kungx- fienx, mv baac oix zuqc longc dongh meih oix zuqc fiev njiec nyei jauv (requires the information).

Dimv mangc duqv fai maiv duqv nyei sou: • Fienx bun hiuv duqv aengx dimv mangc muonc (Bun jaax zinh nyei gorn ganh hnangv):

Fu’jueiv goux mangc nyei gorn caux Domh mienh goux mangc nyei gorn. • Fienx bun hiuv dingc daaih duqv tengx fai mv duqv tengx (Bun jaax zinh nyei gorn ganh

hnangv): Fu’jueiv Goux Mangc nyei gorn caux Domh mienh goux mangc nyei gorn.

Maaih naaiv zeiv formh yaac longx nyei-nzunc baav biauv zong mienh yaac haih duqv zipv fienx: • Taan taux Medicaid caux SCHIP

Naaiv deix zeiv ndorqc daaih se maaih 8½” caux 11”. Maaih zeiv baav se maaih nzangc yiem i bung. Naaiv norm qongx [bold, bracketed fields] se zoux daaih bun meih ganh fiev njiec gorngv dongh haaix dauh se haih tengx meih caux jienv fiuh ziangx formh mingh nor, oix zuqc fungx mingh haaix ndau wuov. Meih oix zuqc fiev njiec meih nyei saengv nyei mbuox dongh haih tengxTemporary Assistance to Needy Families (TANF), fai the State Children’s Health Insurance Program (SCHIP), caux/fai se gorngv maaih nor, The Food Distribution Program on Indian Reservations (FDPIR) wuov deix gorn (program). Naaiv daapc sou yaac aengx maaih taan taux gorngv hnangv haaix nor haih maiv zuqc funx Military Housing Privatization Initiative nyei biauv-jaax zinh zoux nyaanh hlaax. Se gorngv naaiv kang se maiv longc jienv bun meih nor, zorqv cuotv mingh yaac duqv nyei oc. Meih nyei saengv nyei dorngh (State agency) nzunc baav oix meih fungx naaiv zeiv fienx mingh bun ninh mbuo dimv mangc gaax meih horpc zuqc duqv fai maiv duqv. Se gorngv meih maaih waac-naaic nor, fiev fienx mingh bun: [State agency address]

[Insert Center or Sponsoring Organization Letterhead]

May 2011 CACFP Meal Benefit Income Eligibility Form Letter to Households (Child Care Centers)

Page 1 of 2 - Mien

Tong taux domh mienh fai goux nyei mienh:

Naaiv zeiv fienx se bun taux naaiv dauh fu’jueiv dongh duqv dorh mingh bieqc goux mangc fu’jueiv nyei gorn (Child care) nyei domh mienh fai goux ninh nyei mienh oc. [Name of Center] se maaih mbenc nyanc-hopv nyei longx nyei bun dauh dauh fu’jueiv yiem naaic weic ninh mbuo se maaih buonc caux U.S. Department of Agriculture’s (USDA) Child and Adult Care Food Program (CACFP) juangc gong zoux. Naaiv CACFP yaac haih tengx nyanc hopv fai lanx nyei nyaanh, se gorngv meih fu’jueiv oix zuqc yiem goux mangc fu’jueiv gorn nor oc. Tov tengx yie mbuo fiuh jienv naaiv Duqv Tengx Fai Maiv Duqv Nyanc Hopv nyei (Meal Benefit Income Eligibility) Formh nzuonx bun yie mbuo oc. Se gorngv meih fiuh jienv naaiv zeiv formh nor, yie mbuo yaac aengx haih tengx zaah mangc gaax meih nyei fu’jueiv se horpc zuqc duqv nyanc kungx fai duqv cuotv buonc nyanc-hopv nyei jaax zinh oc.

1. Yie oix zuqc tengx dauh dauh fu’jueiv yiem goux mangc nyei gorn fiuh jienv naaiv deix Nyanc Hopv Formh fai? Meih fiuh yietc zeiv naaiv CACFP Duqv Tengx Fai Maiv duqv nyei nyanc hopv formh hnangv se gorngv biauv zong nyei fu’jueiv se juangc norm goux mangc fu’jueiv nyei gorn mingh nor oc. Yie mbuo yaac maiv haih tengx meih, hnangv naaic nor oix zuqc eix jienv njaaux nyei waac fiuh dorng mingh caux oix zuqc fiev njiec dongh haaix nyungc yie mbuo yie mbuo za’gengh qiemx zuqc nyei wuov oc. Fiuh ziangx nor, fungx naaiv zeiv formh mingh bun: [Name of Center, address, phone number].

2. Haaix dauh haih duqv nyanc-hopv kungx mv baac maiv zuqc bun hiuv nyaanh hlaax? Fu’jueiv yiem biauv zong dongh duqv hungh jaa tengx ( Supplemental Nutrition Assistance Program )(SNAP) (dongh zinh ndaangc heuc Food Stamp wuov), Temporary Assistance for Needy Families (TANF), fai Food Distribution Program on Indian Reservations (FDPIR) se duqv nyanc kungx. Hungh jaa luic leiz nyei fu’jueiv (Foster children) caux fu’jueiv doqc yiem Head Start yaac fih hnangv duqv nyanc kungx. Fu’jueiv dongh yiem biauv zong duqv WIC yaac nzunc baav haih duqv nyanc kungx nyei.

3. Haaix dauh haih duqv tengx cuotv buonc nyanc-hopv nyei jaax zinh? Meih nyei fu’jueiv se haih duqv tengx cuotv buonc nyanc-hopv nyei jaax zinh se gorngv meih nyei biauv zong nyei nyaanh hlaax se maiv gauh duqv camv jiex ndaangc domh hungh jaa nyei soux (Federal Income Chart,) dongh gan jienv naaiv zeiv sou daaih wuov. Fu’jueiv dongh yiem biauv zong duqv WIC yaac nzunc baav haih duqv tengx cuotv buonc nyanc hopv nyei jaax zinh nyei.

4. Yie tengx fiuh duqv naaiv zeiv formh nyei fai, se gorngv biauv zong se maiv zeiz benx A^me^li^gaa mienh nor aev (U.S citizen)? Duqv nyei. Meih fai meih nyei fu’jueiv maiv zuqc benx Me^gaa mienh cingx duqv hungh jaa tengx nyanc-hopv nyei jauv yiem naaic goux mangc fu’jueiv nyei gorn (child care center).

5. Haih funx duqv haaix dauh zoux yie nyei biauv zongh mienh? Meih oix zuqc funx nzengc dauh dauh dongh yiem meih nyei biauv zong (Beiv hnangv ong-gux, fai ganh deix gorx-youz, fai pongh youv doic dongh juangc jienv caux meih yiem) yaac juangc jienv longc nyaanh hlaax caux tipv biauv nyei ga’naaiv jaax wuov deix. Meih yaac oix zuqc liemh meih ganh funx yaac caux jienv meih nyei fu’jueiv dauh dauh oc. Se gorngv maaih hungh jaa liuc leiz nyei fu’jueiv nor (foster child) yaac funx duqv nyei.

6. Yie hnangv haaix nor funx yie nyei nyaanh hlaax caux yie gong? Meih oix zuqc mbuox dauh dauh biauv zong mienh nyei jiex daaih naaiv norm hlaax nyei liemh nzou zinh funh nyei nyaanh hlaax (last month’s gross income). Se gorngv jiex daaih naaiv norm hlaax nyei nyaanh hlaax se maiv fih ndongc dongh meih yietc gau duqv nyei nor, meih haih ziu naaic funx gorngv meih yietc gau nyei nyaanh hlaax se duqv mbuoqc ziex. Se gorngv daaih maiv tiuv camv nor, meih haih longc jiex daaih naaiv norm hlaax nyei nyaanh hlaax ziux wuov funx. Se gorngv biauv zong nyei nyaanh hlaax duqv fih ndongc fai gauh nzoqc dongh meih nyei biauv zong horpc zuqc duqv nyei nor, hungh jaa gauh haih tengx nyaanh camv bun goux mangc fu’jueiv nyei gorn. Zuov dimv mangc longx duqv tengx nyanc kungx fai duqv cuotv buonc jaax zinh weic nyaanh hlaax fai ih zanc duqv hungh jaa tengx yaac maaih jienv meih nyei SNAP, TANF, FDPIR case number liuz nor, meih yaac duqv zipv buangv naaiv 12 norm hlaax gu’nyuoz. Se gorngv maaih mienh yiem meih nyei biauv zong ndortv gong, fai ndortv nyaanh hlaax liuz nor duqv gauh zorqc hungh jaax nyei soux wuov nor, meih yaac oix zuqc mbuox bun yie mbuo duqv hiuv oc.

7. Se gorngv yie nyei nyaanh hlaax maiv zanc-zanc duqv mbuoqc wuov nor niv? Fiev njiec dongh meih a’loc duqv nyei nyaanh hlaax. Beiv hnangv, se gorngv yietc hlaax meih a’loc duqv $1000, mv baac meih guangc hnoi gong liuz jiex daaih naaiv norm hlaax meih ziouc duqv $900 hnangv nor, meih oix zuqc funx meih nyei nyaanh hlaax se duqv $1000 oc. Se gorngv meih zoux gong camv jiex ndaangc ziangh hoc (overtime), yaac oix zuqc liemh jienv funx, mv baac se gorngv meih zoux jiex ndaangc ziangh hoc nzunc baav hnangv nor, maiv zuqc funx. Se gorngv meih ndortv gong fai gong-ziouv bun meih nyei gong-mong zoqc njiec nor, funx dongh ih zanc meih duqv nyei nyaanh hlaax hnangv.

8. Se gorngv yie nyei fu’jueiv se benx hungh jaa liuc leiz nyei fu’jueiv niv? Hungh jaa liuc leiz nyei fu’jueiv dongh sic dorngh (court) paaiv daaih caux ganh dauh yiem nor, duqv nyanc kungx nyei. Dauh dauh hungh jaa liuc leiz nyei fu’jueiv yiem biauv zong se duqv nyanc kungx maiv gunv nyaanh hlaax duqv mbuoqc zeix oc. Biauv zong yaac funx duqv hungh jaa liuc leiz nyei fu’jueiv yiem naaiv zeiv Duqv Tengx fai maiv duqv nyei nyanc hopv formh mv baac maiv zuqc funx hungh jaa tengx nyei nyaanh zoux meih nyei nyaanh hlaax oc. Se gorngv biauv zong oix tov hungh jaax tengx naaiv dauh fai naaiv deix hungh jaa liuc leiz nyei fu’jueiv nor heuc mingh lorz [name, address, phone number].

May 2011 CACFP Meal Benefit Income Eligibility Form Letter to Households (Child Care Centers)

Page 2 of 2 - Mien

9. Yie mbuo zoux baeng, yie mbuo oix zuqc liemh jienv biauv-jaax nyaanh funx zoux nyaanh hlaax fai? Se gorngv meih nyei biauv-jaax se maaih buonc benx “Military Housing Privatization Initiative” liuz meih yaac duqv “Family Subsistence Supplemental Allowance” nor, maiv zuqc funx naaiv deix nyaanh zoux meih nyei nyaanh hlaax oc. Aengx caux jienv, fai gorngv meih nyei hmuangv doic duqv cuotv mingh mborqv jaa mi’aqv nor, fungx dongh hungh jaa ganh ca’lengc bun yiem njiec nyei hmuangv doic nyei nyaanh zoux biauv zong nyei nyaanh hlaax hnangv oc. Deng mborqv jaax nyaanh (Combat Pay), liemh jienv “Deployment Extension Incentive Pay” (DEIP) se maiv zuqv funx zoux biauv zong nyei nyaanh hlaax oc. Yietc zungv ganh nyungc nyaanh nor oix zuqc funx zoux meih nyei nyaanh hlaax.

10. (Pricing program only) Dongh yie fiev njiec nyei jauv, oix zuqc dorh mingh zaah mangc nyei fai? Nzunc baav oix zuqc nyei. Yie mbuo nzunc baav fungx sou mingh bun meih senh zoux zorng zengx. Se gorngv yie maiv horpc hnyouv dingc daaih nyei jauv yiem naaiv zeiv formh naaiv norh niv? Meih oix zuqc caux [Center or Sponsoring Organization] gorngv oc.

Yiem naaiv fu’jueiv nyanc hopv nyei gorn, maiv maaih haaix dauh zuqc ki weic ninh nyei fingx, ninh nyei setv, yiem ganh norm deic-bung daaih, benx m’jangc fai m’sieqv, hnyangx-jeiv lunx fai gox, fai waaic fangx oc.

Se gorngv meih maaih ganh deix waac naaic fai qiemx zuqc tengx nor, heuc mingh [phone number].

Ziepc Zuoqv Nyei,

[signature]


May 2011 CACFP Meal Benefit Income Eligibility Form Letter to Households (Tier II Day Care Homes)

Page 1 of 2 - Mien

Tong taux domh mienh fai goux nyei mienh: Naaiv zeiv fienx se bun taux naaiv dauh fu’jueiv dongh duqv dorh mingh bieqc hmuangv doic goux mangc fu’jueiv nyei gorn (family day care home) nyei domh mienh fai goux ninh nyei mien oc. [Name of day care home] se maaih mbenc nyanc-hopv longx nyei bun dauh dauh fu’jueiv yiem naaic weic ninh mbuo se maaih buonc caux U.S. Department of Agriculture’s (USDA) Child and Adult Care Food Program (CACFP) juangc gong zoux. Naaiv CACFP yaac haih tengx nyanc hopv fai lanx nyei nyaanh, se gorngv meih fu’jueiv oix zuqc yiem goux mangc fu’jueiv gorn nor oc. Tov tengx yie mbuo fiuh jienv naaiv Duqv Tengx Fai Maiv Duqv Nyanc Hopv nyei (Meal Benefit Income Eligibility) Formh dongh gan jienv naaiv daapc fienx daaih naaiv oc.

1. Se gorngv yie oix yie nyei fu’jueiv duqv CACFP tengx nyaanh nor, yie oix zuqc fiuh jienv naaiv zeiv Duqv Tengx fai maiv duqv nyei Nyanc Hopv Formh fai? Maiv zuqc, mv baac se gorngv meih fiuh jienv nor, meih nyei goux mangc fu’jueiv nyei gorn gauh duqv nyaanh tengx mbenc nyanc hopv bun meih nyei fu’jueiv. Se gorngv meih oix tengx fiuh nyei nor, fungx nzuonx bun meih nyei goux mangc fu’jueiv nyei gorn (provider) fai bun ninh mbuo nyei nzie gorn mienh (provider’s Sponsor), [Sponsor’s Name] yaac duqv nyei oc. Se gorngv meih oix fungx naaiv zeiv formh mingh bun nzie gorn nyei mienh nor, fiuh dorng mingh fungx nzuonx: [(Name of Center, address, phone number].

___ Fiev jienv meih nyei mbuox wuov deix i norm domh nzaangc-maac (Initial) naaiv se gorngv meih oix bun [Provider’s Name] tengx bun meih nyei naaiv zeiv formh ninh dorh mingh bun nzie gorn nyei mienh nor oc. [Provider’s Name] se maiv maaih leiz la’guaih zaah mangc meih nyei formh oc.

2. Yie oix zuqc tengx dauh dauh fu’jueiv yiem goux mangc nyei gorn fiuh jienv naaiv deix Nyanc Hopv Formh fai? Meih fiuh yietc zeiv naaiv CACFP Duqv Tengx Fai Maiv duqv nyei nyanc hopv formh hnangv se gorngv biauv zong nyei fu’jueiv se juangc norm goux mangc fu’jueiv nyei gorn mingh nor oc. Yie mbuo yaac maiv haih tengx meih, hnangv naaic nor oix zuqc eix jienv njaaux nyei waac fiuh dorng mingh caux oix zuqc fiev njiec dongh haaix nyungc yie mbuo yie mbuo za’gengh qiemx zuqc nyei wuov oc. Fiuh ziangx nor, fungx naaiv zeiv formh mingh bun: [(Name of Center, address, phone number].

3. Haaix dauh haih duqv nyanc-hopv kungx mv baac maiv zuqc bun hiuv nyaanh hlaax? Fu’jueiv yiem biauv zong dongh duqv hungh jaa tengx ( Supplemental Nutrition Assistance Program )(SNAP) (dongh zinh ndaangc heuc Food Stamp wuov), Temporary Assistance for Needy Families (TANF), fai Food Distribution Program on Indian Reservations (FDPIR) se duqv nyanc kungx. Hungh jaa luic leiz nyei fu’jueiv (Foster children) caux fu’jueiv doqc yiem Head Start yaac fih hnangv duqv nyanc kungx. Fu’jueiv dongh yiem biauv zong duqv WIC yaac nzunc baav haih duqv nyanc kungx nyei.


5. Yie tengx fiuh duqv naaiv zeiv formh nyei fai, se gorngv biauv zong se maiv zeiz benx Me^gaa mienh nor aev (U.S citizen)? Duqv nyei. Meih fai meih nyei fu’jueiv maiv zuqc benx Me^gaa mienh cingx duqv hungh jaa tengx nyanc-hopv nyei jauv yiem naaic goux mangc fu’jueiv nyei gorn (child care center).




May 2011 CACFP Meal Benefit Income Eligibility Form Letter to Households (Tier II Day Care Homes)

Page 2 of 2 - Mien

9. Se gorngv yie nyei fu’jueiv se benx hungh jaa liuc leiz nyei fu’jueiv niv? Hungh jaa liuc leiz nyei fu’jueiv dongh sic dorngh (court) paaiv daaih caux ganh dauh yiem nor, duqv nyanc kungx nyei. Dauh dauh hungh jaa liuc leiz nyei fu’jueiv yiem biauv zong se duqv nyanc kungx maiv gunv nyaanh hlaax duqv mbuoqc zeix oc. Biauv zong yaac funx duqv hungh jaa liuc leiz nyei fu’jueiv yiem naaiv zeiv Duqv Tengx fai maiv duqv nyei nyanc hopv formh mv baac maiv zuqc funx hungh jaa tengx nyei nyaanh zoux meih nyei nyaanh hlaax oc. Se gorngv biauv zong oix tov hungh jaax tengx naaiv dauh fai naaiv deix hungh jaa liuc leiz nyei fu’jueiv nor heuc mingh lorz [name, address, phone number]. 10. Yie mbuo zoux baeng, yie mbuo oix zuqc liemh jienv biauv-jaax nyaanh funx zoux nyaanh hlaax fai? Se gorngv meih nyei biauv-jaax se maaih buonc benx “Military Housing Privatization Initiative” liuz meih yaac duqv “Family Subsistence Supplemental Allowance” nor, maiv zuqc funx naaiv deix nyaanh zoux meih nyei nyaanh hlaax oc. Aengx caux jienv, fai gorngv meih nyei hmuangv doic duqv cuotv mingh mborqv jaa mi’aqv nor, fungx dongh hungh jaa ganh ca’lengc bun yiem njiec nyei hmuangv doic nyei nyaanh zoux biauv zong nyei nyaanh hlaax hnangv oc. Deng mborqv jaax nyaanh (Combat Pay), liemh jienv “Deployment Extension Incentive Pay” (DEIP) se maiv zuqv funx zoux biauv zong nyei nyaanh hlaax oc. Yietc zungv ganh nyungc nyaanh nor oix zuqc funx zoux meih nyei nyaanh hlaax

Yiem naaiv fu’jueiv nyanc hopv nyei gorn, maiv maaih haaix dauh zuqc ki weic ninh nyei fingx, ninh nyei setv, yiem ganh norm deic-bung daaih, benx m’jangc fai m’sieqv, hnyangx-jeiv lunx fai gox, fai waaic fangx oc. Se gorngv meih maaih ganh deix waac naaic fai qiemx zuqc tengx nor, heuc mingh [phone number]. Ziepc Zuoqc Hnyouv, [signature].


May 2011 CACFP Meal Benefit Income Eligibility Form Letter to Households (Adult Day Care)

Page 1 of 2 - Mien


CACFP haih tengx nyanc hopv nyaanh domh mienh goux mangc nyei gorn (adult day care) dongh tengx ziux goux mangc ga’nyiec maengx nyei mienh gox mienh hnyangx-jeiv 60 faaux maengx dongh maiv haih tengx liuc leiz ganh nyei buonh sin wuov oc. Tov tengx yie mbuo fiuh jienv naaiv Duqv Tengx Fai Maiv Duqv Nyanc Hopv nyei (Meal Benefit Income Eligibility) Formh ganh jienv naaiv daapv sou daaih naaiv, liuz cingx haih bun gorn duqv zipv nyaanh tengx weic dimv mangc gaax maaih mbuoqc zeix dauh se horpc zuqc duqv nyanc kungx fai duqv cuotv buonc nyanc-hopv nyei jaax zinh oc.

1. Yie oix zuqc tengx dauh dauh fu’jueiv yiem goux mangc nyei gorn fiuh jienv naaiv deix Nyanc Hopv Formh fai? Meih fiuh yietc zeiv naaiv CACFP Duqv Tengx Fai Maiv duqv nyei nyanc hopv formh hnangv se gorngv biauv zong nyei fu’jueiv se juangc norm goux mangc fu’jueiv nyei gorn mingh nor oc. Yie mbuo yaac maiv haih tengx meih, hnangv naaic nor oix zuqc eix jienv njaaux nyei waac fiuh dorng mingh caux oix zuqc fiev njiec dongh haaix nyungc yie mbuo yie mbuo za’gengh qiemx zuqc nyei wuov oc. Fiuh ziangx nor, fungx naaiv zeiv formh mingh bun: [(Name of Center, address, phone number].

2. Haaix dauh haih duqv nyanc-hopv kungx? Fu’jueiv yiem biauv zong dongh duqv hungh jaa tengx ( Supplemental Nutrition Assistance Program )(SNAP) (dongh zinh ndaangc heuc Food Stamp wuov), Temporary Assistance for Needy Families (TANF), fai Food Distribution Program on Indian Reservations (FDPIR) se duqv nyanc kungx. Hungh jaa luic leiz nyei fu’jueiv (Foster children) caux fu’jueiv doqc yiem Head Start yaac fih hnangv duqv nyanc kungx. Fu’jueiv dongh yiem biauv zong duqv WIC yaac nzunc baav haih duqv nyanc kungx nyei.


4. Yie tengx fiuh duqv naaiv zeiv formh nyei fai, se gorngv biauv zong se maiv zeiz benx Me^gaa mienh nor aev (U.S citizen)? Duqv nyei. Meih fai meih nyei fu’jueiv maiv zuqc benx Me^gaa mienh cingx duqv hungh jaa tengx nyanc-hopv nyei jauv yiem naaic goux mangc fu’jueiv nyei gorn (child care center).


6. Yie hnangv haaix nor funx yie nyei nyaanh hlaax caux yie nyei gong? Meih oix zuqc mbuox dauh dauh biauv zong mienh nyei jiex daaih naaiv norm hlaax nyei liemh nzou zinh funh nyei nyaanh hlaax (last month’s gross income). Se gorngv jiex daaih naaiv norm hlaax nyei nyaanh hlaax se maiv fih ndongc dongh meih yietc gau duqv nyei nor, meih haih ziu naaic funx gorngv meih yietc gau nyei nyaanh hlaax se duqv mbuoqc ziex. Se gorngv daaih maiv tiuv camv nor, meih haih longc jiex daaih naaiv norm hlaax nyei nyaanh hlaax ziux wuov funx. Se gorngv biauv zong nyei nyaanh hlaax duqv fih ndongc fai gauh nzoqc dongh meih nyei biauv zong horpc zuqc duqv nyei nor, hungh jaa gauh haih tengx nyaanh camv bun goux mangc fu’jueiv nyei gorn. Zuov dimv mangc longx duqv tengx nyanc kungx fai duqv cuotv buonc jaax zinh weic nyaanh hlaax fai ih zanc duqv hungh jaa tengx yaac maaih jienv meih nyei SNAP, TANF, FDPIR case number liuz nor, meih yaac duqv zipv buangv naaiv 12 norm hlaax gu’nyuoz. Se gorngv maaih mienh yiem meih nyei biauv zong ndortv gong, fai ndortv nyaanh hlaax liuz nor duqv gauh zorqc hungh jaax nyei soux wuov nor, meih yaac oix zuqc mbuox bun yie mbuo duqv hiuv oc.



May 2011 CACFP Meal Benefit Income Eligibility Form Letter to Households (Adult Day Care)

Page 2 of 2 - Mien

9. (Pricing program only) Dongh yie fiev njiec nyei jauv, oix zuqc dorh mingh zaah mangc nyei fai? Nzunc baav oix zuqc nyei. Yie mbuo nzunc baav fungx sou mingh bun meih senh zoux zorng zengx. Se gorngv yie maiv horpc hnyouv dingc daaih nyei jauv yiem naaiv zeiv formh naaiv norh niv? Meih oix zuqc caux [Center or Sponsoring Organization] gorngv oc.

Yiem naaiv CACFP nyei gorn, maiv maaih haaix dauh zuqc ki weic ninh nyei fingx, ninh nyei setv, yiem ganh norm deic-bung daaih, benx m’jangc fai m’sieqv, hnyangx-jeiv lunx fai gox, fai waaic fangx oc. Se gorngv meih maaih ganh deix waac naaic fai qiemx zuqc tengx nor, heuc mingh [phone number]. Ziepc Zuoqc Hnyouv, [signature]

[Insert Sponsor Letterhead]

May 2011 CACFP Meal Benefit Income Eligibility Form Letter to Provider (Tier I or Provider’s Own Children)

Page 1 of 2 - Mien

Tong taux gorn nyei mienh: Oix duqv zipv Tier I wuov kaax nzuic nzuonx nyei nyaanh, fai oix duqv U.S. Department of Agriculture’s Child and Adult Care Food Program (CACFP), nzuic nzuonx fu’jueiv nyanc hopv nyei zinh nor, oix zuqc fiuh dorng naaiv zeiv Duqv Tengx fai maiv duqv nyei nyei nyanc hopv formh, senh meih nyei mbuox njiec naaiv formh liuz fungx nzuonx bun yie mbuo oc. 1. Yie hnangv haaix nor haih duqv Tier I nzuic nzuonx wuov kaax fu’jueiv nyei nyanc hopv zinh? (a) Meih yiem zuqc deic se dongh hungh jaa funx oix zuqc tengx nyei laangz-deic (economic need area) weic ninh mbuo duqv zaah mangc horqc dorngh nyei jauv fai ei hungh jaa zaah mangc naaic deix dorngh nyei leiz, fai (b) dongh ninh mbuo dimv mangc liuz meih fiev njiec nyei jauv se buatc horpc zuqc tengx nyei.

2. Haaix dauh tengx yie zaah mangc gorngv yie nyei goux mangc fu’jueiv fai domh mienh gorn (child or adult day care) se duqv Tier I tengx? Yie mbuo nyei gong-dorngh (office) zaah mangc gaax horpc zuqc tengx meih maiv horpc. Yie mbuo longc meih fiev njiec yiem naaiv zeiv Duqv Tengx Fai Maiv duqv nyei nyanc hopv formh nyei jauv zaah mangc. Meih oix zuqc jangx jienv fiuh dorng yaac senh meih nyei mbuox njiec naaiv formh; biux mengh tong gorngv meih nyei biauv zong nyei nyaanh hlaax (maiv zeiz kungx dongh meih zornc naaiv norm goux mangc mienh nyei gorn nyei saengh eix nyei nyaanh hlaax hnangv); aengx caux jienv maaih sou-gorn fiev jienv gorngv meiih nyei nyaanh hlaax se duqv mbuoqc ziex. Fiuh dorng naaiv zeiv formh liuz fungx mingh bun: [at name, address, phone number].

3. Yie oix zuqc fungx haaix nyungc sou gorn caux naaiv zeiv Duqv Tengx Fai Maiv Duqv Nyei Nyanc Hopv Fornh nzuonx? Se gorngv ba’hnyangx wuov meih daaih zoux ziux goux mangc hmuangv doic nyei saengh eix nor (family day care business), fungx kuaaiv siangh nzou zinh nyei sou (most recent tax return) ganh jienv daaih, yaac liemh jienv Schedule C Se gorngv meih nyei siangh nzouh zinh sou (most recent tax return) caux Schedule C maiv maaih gorngv meih yietc zungv zornc duqv mbaqc ziex nor meih oix zuqc ganh fungx zeiv sou taan gorngv meih ih nzanc zornc duqv mbaqc ziex caux longc cuotv mbaqc ziex oc. Oix hnangv naaiv zoux fungx nzuonx nor, oix zuqc maaih jienv sou gorn gorngv meih oix zuqc maaih gong nyei nyaanh hlaax fienx (work payment statements) caux jienv ganh nyungc nyaanh hlaax nyei fienx. Dongh meih oix longc fungx mingh naaiv deix fienx naaiv yaac oix zuqc maaih jienv mbuox gorngv haaix dauh duqv zipv naaiv deix nyaanh hlaax, dongh ziangh haaix fungx daaih bun, duqv zipv mbuoqc ziex, aengx caux duqv zipv ndongc haaix maqc?

4. Yie hnangv haaix nor haih duqv hungh jaa tengx nzuic yie ganh nyei fu’jueiv nyei nyanc hopv nyaanh? Hungh jaa nyei leiz gorngv meih oix zuqc fiuh jienh naaiv zeiv formh se gorngv meih yaac oix ninh mbuo maaih buonc nzuic meih ganh nyei fu’jueiv nyei nyanc hopv jaax zinh nor aah. Maiv gunv gorngv meih yiem nyei laangz-deic se benx horpc hungh jaa zuqc tengx nyei, fai meih nyei biauv se horpc zuqc duqv “tier I” tengx mi’aqv, meih oix zuqc fiuh dorngh naaiv zeiv formh. Yie mbuo nyei gong-dorngh nzunc baav oix zuqc zaah mangc dongh meih fiev njiec fungx nzuonx nyei jauv.

5. Se gorngv yie maiv zeix yiem zuqc laangz-deic dongh hungh jaa horpc zuqc tengx nyei wuov, fai maiv oix fungx nzuonx naaiv zeiv Duqv Tengx Fai Maiv Duqv nyei Nyanc Hopv Formh nor, yie aengx maaih haaix diuc jauv tengx yie duqv hungh jaa nzuic nyaanh yie? Meih duqv nzuic gauh zorqc deix weic meih duqv tengx uiz fu’jueiv yiem meih nyei ziux goux mangc hmuangv doic nyei biauv (family day care home).

6. Dongh yie fiev njiec nyei jauv, oix zuqc dorh mingh zaah mangc nyei fai? Nzunc baav oix zuqc nyei. Yie mbuo nzunc baav fungx sou mingh bun meih senh zoux zorng zengx. Se gorngv yie maiv horpc hnyouv dingc daaih nyei jauv yiem naaiv zeiv formh naaiv norh niv? Meih oix zuqc caux [Center or Sponsoring Organization] gorngv oc.

7. Haih funx duqv haaix dauh zoux yie nyei biauv zongh mienh? Meih oix zuqc funx nzengc dauh dauh dongh yiem meih nyei biauv zong (Beiv hnangv ong-gux, fai gorx-youz, fai pongh youv doic dongh juangc jienv caux meih yiem) yaac juangc jienv longc nyaanh hlaax caux tipv biauv nyei ga’naaiv jaax wuov deix. Meih yaac oix zuqc liemh meih ganh funx yaac caux jienv meih nyei fu’jueiv dauh dauh oc.


9. Yie tengx fiuh duqv naaiv zeiv formh nyei fai, se gorngv biauv zong se maiv zeiz benx Me^gaa mienh nor aev (U.S citizen)? Duqv nyei. Meih fai meih nyei fu’jueiv maiv zuqc benx Me^gaa mienh

10. Se gorngv yie nyei fu’jueiv se benx hungh jaa liuc leiz nyei fu’jueiv niv? Hungh jaa liuc leiz nyei fu’jueiv se duqv nyanc kungx maiv gunv ninh mbuo ganh maaih mbuoqc zeix nyaanh fai dongh ninh mbuo caux yiem nyei biauv zong se duqv nyaanh mbuoqc ziex oc. Se gorngv biauv zong oix tov hungh jaax tengx naaiv dauh fai naaiv deix hungh jaa liuc leiz nyei fu’jueiv nor heuc mingh lorz [name, address, phone number].

May 2011 CACFP Meal Benefit Income Eligibility Form Letter to Provider (Tier I or Provider’s Own Children)

Page 2 of 2 - Mien


Yiem naaiv fu’jueiv nyanc hopv nyei gorn CACFP, maiv maaih haaix dauh zuqc ki weic ninh nyei fingx, ninh nyei setv, yiem ganh norm deic-bung daaih, benx m’jangc fai m’sieqv, hnyangx-jeiv lunx fai gox, fai waaic fangx oc. Se gorngv meih maaih haaix nyungc waac naaic fai qiemx zuqc tengx nor, heuc mingh [phone number]. Zieqc Zuoqv Hnyouv, [signature]

INSTRUCTIONS FOR COMPLETING THE CACFP

MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)

May 2011 CACFP Meal Benefit Income Eligibility Form Child Care Instructions

Page 1 of 2 - Mien

Eix jienv naaiv deix njaaux nyei leiz zoux se gorngv meih nyei biauv zong duqv SNAP, TANF fai FDPIR:

Part 1: Fiev njiec yietc zungv fu’jueiv dongh mingh naaic goux fu’jueiv gorn (Child Care) caux jienv dauh dauh biauv zong mienh. Part 2: Fiev njiec ninh mbuo nyei “case number” dongh dauh dauh (liemh jienv domh mienh) duqv hungh jaa tengx [State SNAP] fai [State

TANF] fai [FDPIR] nyei nyaanh. Part 3: Nqenx cuotv naaiv kang. Part 4: Nqenx cuotv naaiv kang. Part 5: Senh meih nyei mbuox njiec naaiv formh. Maiv zuqc fiev njiec nqa’haav laai wuov deix biei norm social number oc. Part 6: Dau naaiv deix waac-naaic yaac duqv nyei, yiem meih ganh eix.

Se gorngv meih tengx fiuh naaiv dauh fu’jueiv se benx HUNGH JAA LIUC LEIZ NYEI FU’JUEIV nor, eix jienv naaiv kangx njaaux nyei waac zoux.

Se gorngv yietc zungv biauv zongh nyei fu’jueiv se benx hungh jaa liuc leiz nyei fu’jueiv, fai se gorngv meih tengx hungh jaa liuc leiz nyei fu’jueiv fiuh naaiv zeiv formh oc:

Part 1: Fiev njiec yietc zungv hungh jaa liuc leiz nyei fu’jueiv nyei mbuox. Liuz yaac kitc jienv wuov norm qongx gorngv naaiv dauh fu’jueiv se benx hungh jaa liuc leiz nyei fu’jueiv oc. Part 2: Nqenx cuotv naaiv kang. Part 3: Nqenx cuotv naaiv kang. Part 4: Nqenx cuotv naaiv kang. Part 5: Senh meih nyei mbuox njiec naaiv formh. Maiv zuqc fiev njiec nqa’haav laai wuov deix biei norm social number oc. Part 6: Dau naaiv deix waac-naaic yaac duqv nyei, yiem meih ganh eix

Se gorngv maaih deix biauv zongh nyei fu’jueiv se benx hungh jaa liuc leiz nyei fu’jueiv nor:

Part 1: Fiev njiec yietc zungv fu’jueiv dongh mingh naaic goux fu’jueiv gorn (Child Care) caux jienv dauh dauh biauv zong mienh. Se gorngv maaih haaix dauh liemh jienv fu’jueiv maiv duqv nyaanh hlaax nor, oix zuqc kitc jienv wuov norm qongx dongh gorngv “maiv maaih nyaanh hlaax” wuov norm qongx. Se gorngv fu’jueiv se benx hungh jaa liuc leiz nyei fu’jueiv nor yaac oix zuqc kitc jienv wuov norm qongx dongh gorngv “hungh liuc leiz nyei fu’jueiv”. Part 2: Se gorngv biauv zongh se maiv maaih “case number” nor, nqenx cuotv naaiv kang. Part 3: se gorngv meih tengx fiuh formh naaiv dauh fu’jueiv se benx njiouh huaax, fai gong-torngx, fai beaux domh mienh nyei fu’jueiv nor, kitc

jienv horpc wuov norm qongx liuz caux jienv heuc mingh [your school, homeless liaison, migrant coordinator]. Maiv zeix nor, nqenx cuotv naaiv kang.

Part 4: Ganh ziux jienv naaiv njaaux nyei leiz zoux hnangv haaix nor haih mbuox tong meih nyei biauv zong nyei yietc zungv nyaanh hlaax yiem naaiv norm hlaax fai jiex daaih wuov norm hlaax.

Column A – Mbuox: Fiev jienv dauh dauh biauv zong mienh nyei mbuox dongh caux meih juangc nyaanh hlaax longc yaac juangc jienv tipv biauv nyei ga’naaiv jaax, maiv gunv maaih cien fai maiv maaih (beiv hnangv ong fai gux, gorx-youz, fai pongh youv doic dongh caux jienv meih juangc yiem) wuov deix mienh nyei nyaanh hlaax oc. Liemh jienv meih ganh yaac caux meih yiem nyei dauh dauh fu’jueiv. Se gorngv dorngx maiv gaux fiev, ganh fiev hietv kuaaiv liuz gaapc jienv naaiv zeiv fienx fungx nzuonx oc.

Column B – Liemh nzou funx nyei nyaanh hlaax (Gross Income) caux jienv duqv zipv nyaanh hlaax ndongc haaix maqc: Yietc dauh biauv zong nyei mienh laanh, fiev njiec gorngv ninh duqv haaix nyungc nyaanh hlaax. Meih yaac oix zuqc gorngv ninh duqv zipv ndongc haaix maqc-norm-norm la’baaix, nqaeqv norm la’baaix, yietc hlaax zipv i nzunc fai norm-norm hlaax.

Box 1: Oix zuqc fiev njiev ninh nyei liemh nzou funx nyei nyaanh hlaax (gross income), maiv zeix dongh funx liuz nzou zingh nyei nyaanh hlaax (take-home pay.) Liemh nzou funx nyei nyaanh hlaax se dongh maiv gaengh zuqc zorqv cuotv nzou nyei buonc fai dongh haaix nyungc oix zuqc ca’lengc zorqv cuotv nyei buonc. Meih yaac oix zuqc maaih meih nyei nyaanh hlaax nyei fienx (pay stub) fai meih nyei gong-ziouv gorngv mbuox yaac duqv nyei. Box 2: Fiev njiec dauh dauh mienh yietc hlaax duqv mbuoqc zeix maiv gunv benx welfare nyaanh, fai fu’jueiv nyei support, aux-nqox nyei support nyei nyaanh. Box 3: Fiev njiec ding-gong (retirement), fai Socical Security, fai , fai (SSI), fai zoux baeng (VA) , fai zoux maiv duqv gong (disability) nyei nyaanh hlaax. Box 4: Fiev njiec YIETC ZUNGV DIEH NYUNGC NYEI NYAANH HLAAX maiv gunv benx dingh njiec zoux gong zuqc mun zipv nyei nyaanh (Worker’s Compensation), ndortv gong fai ngaengc leiz maiv zoux gong zipv nyei nyaanh (unemployment or strike benefits), mienh maiv caux yiem yaac a’loc tengx nyaanh meih caux zipv dieh nyungc nyei nyaanh, caux aengx ganh maaih haaix nyungc nyaanh hlaax. Se gorngv meih ganh tengx meih ganh zoux gong nor, fiev njiec dongh meih longc cuotv liuz corc aengx zengc njiec mbuoqc zeix yiem Box 1. Fiev meih nyei nyaanh hlaax njiec yiem Box 4 se gorngv meih ganh maaih meih nyei saeng-eix, fai zoux ndeic,fai maaih biauv saauh bun mienh yiem nyei nyaanh hlaax. Maiv zuqc funx SNAP, FDPIR, WIC fai domh hung jaa (Federal) tengx doqc sou nyei nyaanh. Se gorngv meih duqv Military Housing Privatization Initiative fai duqv mborqv jaax nyaanh nor, maiv zuqc funx, yaac caux jienv maiv zuqc funx meih nyei biauv jaax nyaanh benx meih nyei nyaanh hlaax.

Part 5: biauv zong domh mienh oix zuqc senh naaiv zeiv formh aengx caux hietv jienv ninh nyei nqa’haav-laai wuov deix biei norm social Security Number fai kitc jienv wuov norm qongx gorngv maiv maaih oc.

Part 6: Dau naaiv deix waac-naaic yaac duqv nyei, yiem meih ganh eix.

INSTRUCTIONS FOR COMPLETING THE CACFP

MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)

May 2011 CACFP Meal Benefit Income Eligibility Form Child Care Instructions

Page 2 of 2 - Mien

YIETC ZUNGV GANH DEIX BIAUV ZONG MIENH, liemh jienv duqv WIC tengx nyei biauv zong, oix zuqc ei naaiv deix liez fiuh:

Part 1: Fiev njiec yietc zungv fu’jueiv caux biauv zong mienh nyei mbuox. Se gorngv dongh haaix dauh, liemh jienv fu’jueiv, dongh maiv maaih nyaanh hlaax, meih oix zuqc kitc jienv wuov qongx dongh gorngv “Maiv Maaih Nyaanh Hlaax” wuov.

Part 2: Nqenx cuotv naaiv kang. Part 3: Nqenx cuotv naaiv kang. Part 4: Ei jienv leiz, tov bun hiuv taux biauv zong naaiv norm hlaax caux jiex daaih wuov norm hlaax duqv zipv nyei nyaanh hlaax.

Column A – Name: Fiev jienv dauh dauh biauv zong mienh nyei mbuox dongh caux meih juangc nyaanh hlaax longc yaac juangc jienv tipv biauv nyei ga’naaiv jaax, maiv gunv maaih cien fai maiv maaih (beiv hnangv ong fai gux, gorx-youz, fai pongh youv doic dongh caux jienv meih juangc yiem) wuov deix mienh nyei nyaanh hlaax oc. Liemh jienv meih ganh yaac caux meih yiem nyei dauh dauh fu’jueiv. Se gorngv dorngx maiv gaux fiev, ganh fiev hietv kuaaiv liuz gaapc jienv naaiv zeiv fienx fungx nzuonx oc. Column B – Liemh nzou funx nyei nyaanh hlaax (Gross Income) caux jienv duqv zipv nyaanh hlaax ndongc haaix maqc: Yietc dauh biauv zong nyei mienh laanh, fiev njiec gorngv ninh duqv haaix nyungc nyaanh hlaax. Meih yaac oix zuqc gorngv ninh duqv zipv ndongc haaix maqc-norm-norm la’baaix, nqaeqv norm la’baaix, yietc hlaax zipv i nzunc fai norm-norm hlaax.

Box 1: Oix zuqc fiev njiev ninh nyei liemh nzou funx nyei nyaanh hlaax (gross income), maiv zeix dongh funx liuz nzou zingh nyei nyaanh hlaax (take-home pay.) Liemh nzou funx nyei nyaanh hlaax se dongh maiv gaengh zuqc zorqv cuotv nzou nyei buonc fai dongh haaix nyungc oix zuqc ca’lengc zorqv cuotv nyei buonc. Meih yaac oix zuqc maaih meih nyei nyaanh hlaax nyei fienx (pay stub) fai meih nyei gong-ziouv gorngv mbuox yaac duqv nyei. Box 2: Fiev njiec dauh dauh biauv zong mienh nyei nyaanh hlaax maiv gunv benx welfare nyaanh, fai fu’jueiv nyei support, aux-nqox nyei support nyei nyaanh hlaax. Box 3: Fiev njiec ding-gong nyaanh (retirement), fai Socical Securit nyaanh, fai (SSI) nyaanh, fai zoux baeng (VA) nyaanh, fai zoux maiv duqv gong (disability) nyei nyaanh hlaax. Box 4: Fiev njiec YIETC ZUNGV DIEH NYUNGC NYEI NYAANH HLAAX maiv gunv benx dingh njiec zoux gong zuqc mun zipv nyei nyaanh (Worker’s Compensation), ndortv gong fai ngaengc leiz maiv zoux gong zipv nyei nyaanh (unemployment or strike benefits), mienh maiv caux yiem yaac a’loc tengx nyaanh meih caux zipv dieh nyungc nyei nyaanh, caux aengx ganh maaih haaix nyungc nyaanh hlaax. Se gorngv meih ganh tengx meih ganh zoux gong nor, fiev njiec dongh meih longc cuotv liuz corc aengx zengc njiec mbuoqc zeix yiem Box 1. Fiev meih nyei nyaanh hlaax njiec yiem Box 4 se gorngv meih ganh maaih meih nyei saeng-eix, fai zoux ndeic,fai maaih biauv saauh bun mienh yiem nyei nyaanh hlaax. Maiv zuqc funx SNAP, FDPIR, WIC fai domh hung jaa (Federal) tengx doqc sou nyei nyaanh. Se gorngv meih duqv Military Housing Privatization Initiative fai duqv mborqv jaax nyaanh nor, maiv zuqc funx, yaac caux jienv maiv zuqc funx meih nyei biauv jaax nyaanh benx meih nyei nyaanh hlaax.

Part 5: biauv zong domh mienh oix zuqc senh naaiv zeiv formh aengx caux hietv jienv ninh nyei nqa’haav-laai wuov deix biei norm social

Security Number fai kitc jienv wuov norm qongx gorngv ninh maiv maaih wuov oc. Part 6: Dau naaiv deix waac-naaic yaac duqv nyei, yiem meih ganh eix.

Naaiv se porv mengh taux yie mbuo hnangv haaix nor longc meih fiev njiec nyei jauv.

Longc Baengh Leiz: Naaiv se porv mengh taux se gorngv meih haiz ninh mbuo longx leiz-fingx maiv baengh nor, meih maaih leiz hnangv haaix nor zoux.

NJAAUX LEIZ HNANGV HAAIX NOR FIUH CACFP NYEI DUQV TENGX FAI MAIV DUQV NYEI NYANC HOPV FORMH (Domh mienh nyei gorn)

May 2011 CACFP Meal Benefit Income Eligibility Form Adult Care Instructions

Page 1 of 1 - Mien

Se gorngv meih nyei biauv zong duqv hungh jaa tengx SNAP, FDPIR, SSI fai Medicaid nor, ei jienv naaiv deix njaaux nyei leiz fiuh oc.

Part 1: Fiev njiec yietc zungv domh mienh nyei mbuox dongh duqv naaiv kaax nyaanh wuov. Part 2: Fiev njiec ninh mbuo nyei “case number” dongh dauh dauh duqv hungh jaa tengx [State SNAP] fai [FDPIR] fai [SSI] fai [Medicaid]

nyei nyaanh. Part 3: Nqenx cuotv naaiv kang. Part 4: Senh meih nyei mbuox njiec naaiv formh. Maiv zuqc fiev njiec nqa’haav-laai wuov deix biei norm social number oc. Part 5: Dau naaiv deix waac-naaic yaac duqv nyei, yiem meih ganh eix.

YIETC ZUNG GANH DEIX BIAUV ZONG MIENH, oix zuqc ei naaiv deix liez fiuh:

Part 1: Fiev dauh dauh yiem biauv zong nyei mbuox dongh maaih buonc yiem naaiv norm gorn. Se gorngv maiv maaih nyaanh hlaax nor, oix zuqc kitc jienv wuov norm qonqx dongh gorngv “Maiv Maaih Nyaanh Hlaax.”

Part 2: Nqenx cuotv naaiv kang. Part 3: jienv leiz, tov bun hiuv taux biauv zong naaiv norm hlaax caux jiex daaih wuov norm hlaax duqv zipv nyei nyaanh hlaax.

Column A – Mbuox: Fiev njiec naaiv dauh maaih buonc yiem naaiv norm gorn nyei mienh caux ninh nyei auv fai nqox nyei mbuox, yaac caux jienv dauh dauh dongh caux meih juangc nyaanh hlaax caux juangc yiem juangc nyanc. Column B – Liemh nzou funx nyei nyaanh hlaax (Gross Income) caux jienv duqv zipv nyaanh hlaax ndongc haaix maqc. Dongh haaix dauh duqv maaih buonc caux yiem naaiv norm gorn fai biauv zong mienh dongh maaih buonc wuov, fai ninh nyei auv-nqox, fai dongh haaix dauh caux ninh yiem nyei mienh wuov, fiev ninh duqv haaix nyungc nyaanh hlaax. Meih yaac oix zuqc gorngv ninh duqv zipv ndongc haaix maqc-norm-norm la’baaix, nqaeqv norm la’baaix, yietc hlaax zipv i nzunc fai norm-norm hlaax.

Box 1: Oix zuqc fiev njiev ninh nyei liemh nzou funx nyei nyaanh hlaax (gross income), maiv zeix dongh funx liuz nzou zingh nyei nyaanh hlaax (take-home pay.) Liemh nzou funx nyei nyaanh hlaax se dongh maiv gaengh zuqc zorqv cuotv nzou nyei buonc fai dongh haaix nyungc oix zuqc ca’lengc zorqv cuotv nyei buonc. Meih yaac oix zuqc maaih meih nyei nyaanh hlaax nyei nyaanh piux dueiv (pay stub) fai meih nyei gong-ziouv gorngv mbuox yaac duqv nyei. Box 2: Fiev njiec dauh dauh mienh yietc hlaax duqv mbuoqc zeix maiv gunv benx welfare nyaanh, fai fu’jueiv nyei support, aux-nqox nyei support nyei nyaanh. Box 3: Fiev njiec ding-gong (retirement), fai Socical Security, fai , fai (SSI), fai zoux baeng (VA) , fai zoux maiv duqv gong (disability) nyei nyaanh hlaax. Box 4: Fiev njiec YIETC ZUNGV DIEH NYUNGC NYEI NYAANH HLAAX maiv gunv benx dingh njiec zoux gong zuqc mun zipv nyei nyaanh (Worker’s Compensation), ndortv gong fai ngaengc leiz maiv zoux gong zipv nyei nyaanh (unemployment or strike benefits), mienh maiv caux yiem yaac a’loc tengx nyaanh meih caux zipv dieh nyungc nyei nyaanh, caux aengx ganh maaih haaix nyungc nyaanh hlaax. Se gorngv meih ganh tengx meih ganh zoux gong nor, fiev njiec dongh meih longc cuotv liuz corc aengx zengc njiec mbuoqc zeix yiem Box 1. Fiev meih nyei nyaanh hlaax njiec yiem Box 4 se gorngv meih ganh maaih meih nyei saeng-eix, fai zoux ndeic,fai maaih biauv saauh bun mienh yiem nyei nyaanh hlaax. Maiv zuqc funx SNAP, FDPIR, WIC fai domh hung jaa (Federal) tengx doqc sou nyei nyaanh. Se gorngv meih duqv Military Housing Privatization Initiative fai duqv mborqv jaax nyaanh nor, maiv zuqc funx, yaac caux jienv maiv zuqc funx meih nyei biauv jaax nyaanh benx meih nyei nyaanh hlaax.

Part 4: biauv zong domh mienh oix zuqc senh naaiv zeiv formh aengx caux hietv jienv ninh nyei nqa’haav-laai wuov deix biei norm social

Security Number fai kitc jienv wuov norm qongx gorngv ninh maiv maaih wuov oc. Part 5: Dau naaiv deix waac-naaic yaac duqv nyei, yiem meih ganh eix.

Naaiv se porv mengh taux yie mbuo hnangv haaix nor longc meih fiev njiec nyei jauv

Longc Baengh Leiz: Naaiv se porv mengh taux se gorngv meih haiz ninh mbuo longx leiz-fingx maiv baengh nor, meih maaih leiz hnangv haaix nor zoux.

CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)

May 2011 CACFP Meal Benefit Income Eligibility Child Care Form

Page 1 of 2 - Mien

Part 1. Yietc zungv biauv zong mienh laanh

Yietc zungv fu’jueiv nyei mbuo:

Biauv zong nyei fu’jueiv nyei mbuox (First, Middle Initial, Last)

KITC JIENV SE GORNGV FU’JUEIV BENX HUNGH JAA LIUC LEIZ NYEI FU’JUEIV (FOSTER CHILD )(SIC DORNGH FAI WELFARE DORNGH PAAIV) * SE GORNGV FU’JUEIV SE YIETC ZUNGV BENX HUNGH JAA LIUC LEIZ NYEI FU’JUEIV NOR NQENX MINGH TAUX PART 5 SENH JIENV MBUOX.

KITC SE GORNGV MAIV MAAIH NYAANH HLAAX

Part 2. Hungh jaa nyaanh (Benefits): Se gorngv haaix dauh yiem biauv zong duqv , , fai nor, fiev jienv ninh mbuox caux ninh “case number” oc. Se gorngv maiv maaih haaix dauh duqv naaiv kang nyaanh nor, nqenx mingh taux part 3.

MBUOX:_________________________________________________ CASE NUMBER: _________________________________

Part 3. Se gorngv dongh meih tengx fiuh formh naaiv dauh fu’jueiv se benx njiouh huaax fai gong-torngx (migrant), fai biaux domh mienh nor, kitc jienv horpc wuov norm qongx liuz yaac heuc mingh Njiouh huaax Gong-torngx Biaux domh mienh Part 4. Yietc zungv biauv zong nyei nyaanh hlaax, liemh jienv nzou funx nyei nyaanh hlaax (gross income)—Meih yaac oix zuqc mbuox yie mbuo meih duqv mbuoqc ziex caux ndongc haaix maqc.

B. Liemh nzou nyei nyaanh hlaax caux duqv ndongc haaix maqc.

A. Mbuox (fiev dongh yiem biauv zong maaih nyaanh hlaax wuov deix hnangv)

1. Gong-zinh dongh maiv gaengh jaamv cuotv

2. Welfare, fu’jueiv nyei support, auv-nqox nyei support.

3. Pensions, retirement, Social Security, SSI, VA nyei nyaanh hlaax

4. Yietc Zungv Dieh Nyungc Nyei Nyaanh Hlaax

(Beiv hnangv) Jane Smith $200/ leiz-baaix _____ $150/ nqaeqv norm leiz-baaix_ $100/ yietc hlaax__________ $______/________

$ $ $ $

$ $ $ $

$ $ $ $

$ $ $ $

$ $ $ $

Part 5. Senh Jienv Mbuox Caux Nqa’haav Laai Wuov Deix Biei Norm “Social Number” (Domh Mienh Oix Zuqc Senh)

Domh mienh yiem biauv zong oix zuqc senh jienv mbuox njiec naaiv zeiv formh. Se gorngv Part 3 se fiuh dorng nor, dongh wuov laanh domh mienh senh naaiv zeiv formh naaiv oix zuqc fiev jienv ninh nyei nqa’haav-laai wuov deix biei norm Social Number fai kitc jienv wuov norm qongx dongh gorngv “Yie maiv maaih Social number” wuov qongx. (Mbienv naaiv pin zeiv nzuonx nqa'haav nqaang mangc ninh mbuo nyei leiz oc.)

Yie laengz gorngv yietc zungv yie fiev njiec naaiv zeiv formh se zien nyei caux jienv yietc zungv nyaanh hlaax yaac fiev njiec nzengc mi’aqv. Yie bieqc hnyouv goux mangc mienh nyei gorn haih duqv zipv domh hungh jaa tengx nyaanh (Federal funds) weic yie fiev njiec nyei jauv. Yie bieqc hnyouv CACFP nyei gong-mienh maaih leiz dimv mangc dongh yie fiev njiec nyei. Yie bieqc hnyouv se gorngv yie baac-baac fiev jaav nyei jauv njiec nor, yie nyei fu’jueiv nziex maiv haih duqv hungh jaa tengx nyanc hopv, liuz yie yaac haih zuqc hungh jaa hoic. Senh mbuox: ________________________________________________ Fiev mbuox: _________________________________________________

Hnoi: _______________________________________________________

Dorngx yiem: _________________________________________________ Phone Number: ______________________________________________

Mungv: _____________________________________________________ Saengv: ___________________ Zip Code: _______________________

Nqa’haav-laai wuov deix biei norm Social Number: * * * - * * - ___ ___ ___ ___ Yie maiv maaih Social Number

CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)

May 2011 CACFP Meal Benefit Income Eligibility Child Care Form

Page 2 of 2 - Mien

Part 6. Fu’jueiv nyei fingx (dau yaac longx nyei)

Ginv norm fingx: Ginv norm fai i norm fingx:

Hispanic fai Latino

Maiv zeiz Hispanic fai Latino

E^sie Aa^me^li^gaa Indian fai Alaska nyei janx

Janx-Baeqc Hawaii nyei janx fai ganh fingx koiv-nzou (island) nyei janx

Janx-jieqv fai Aa^me^li^gaa nyei Aa^fi^gaa

Maiv dungx fiuh naaiv nqanx. Naaiv bun ninh mbuo nyei dorngh fiuh hnangv. Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12

Total Income: ____________ Per: Week, Every 2 Weeks, Twice A Month, Month, Year Household size: _________

Categorical Eligibility: ___ Date Withdrawn: ________ Eligibility: Free___ Reduced___ Denied___ Tier I_____ Tier II____

Reason: _____________________________________________________________________________________________________

Temporary: Free_____ Reduced_____ Time Period: ______________________________(expires after _____ days)

Determining Official’s Signature: _______________________________________________________________ Date: ______________

Confirming Official’s Signature: ________________________________________________________________ Date: ______________

Follow-up Official’s Signature: _________________________________________________________________ Date:______________

Meih nyei fu’jueiv nziex haih duqv nyanc kungx fai zuqc cuotv buonc jaax-zinh se gorngv meih nyei biauv zong nyei nyaanh hlaax duqv mbuoqc fai gauh nzoqc yiem naaiv norm qongx duqv fiev njiec daaih nyei.

Richard B. Russell Horqc Dorngh Nyanc Hopv Nyei Domh Leiz (Richard B. Russell National School Lunch Act) dingc daaih formh oix zuqc duqv zipv hiuv naaiv deix jauv. Meih maiv zuqc taan taux meih nyei jauv bun yie mbuo, mv baac se gorngv meih maiv zoux nor, yie mbuo yaac maiv haih tengx meih nyei fu’jueiv nyanc kungx fai cuotv buonc jaax-zinh. Se gorngv meih nyei fu’jueiv fai hungh jaa liuc leiz nyei fu’jueiv duqv Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program fai Food Distribution Program on Indian Reservations (FDPIR) maaih jienv (FDPIR) “case number” fai ganh nyungc porv mengh gorngv domh mienh senh naaiv zeiv formh se maiv maaih Social Security Number. Yie mbuo longc meih fiev njiec nyei jauv zaah mangc gaax meih horpc zuqc duqv fai maiv duqv hungh jaa tengx nyanc kungx fai cuotv buonc jaax zinh, aengx caux bun gong-mienh maaih leiz longc weic tengx zangv gorn.

Longc Baengh Leiz (non-discrimination): Naaiv deix waac njaaux taux oix zuqc hnangv haaix nor zoux se gorngv meih hnamv daaih mienh ki zuqc meih. “Ei Domh Hungh Jaa Nyei Doz-Leiz (Federal Law and U.S. Department of Agriculture Policy), maiv yuangh naaiv norm gorn ki haaix dauh weic ninh nyei fingx, ninh nyei setv, yiem ganh norm deic-bung daaih, benx m’jangc fai m’sieqv, hnyangx-jeiv lunx fai gox, fai waaic fangx. Se gorngv meih oix gox zongc mienh longc leiz maiv baengh nor, tov fiev fienx mingh bun USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 fai heuc kungx (866) 632-9992 (Gorngv waac). Haaix dauh m’normh maiv mbienc fai gorngv waac maiv junh nor, longc Federal Relay Service (800) 877-8339; fai (800) 845-6136 (Spanish) heuc USDA yaac duqv nyei. USDA benx longc baengh leiz tengx mingh nyei gorn yaac zeiz longc baengh leiz nyei gong-ziouv.”

Biauv zong mienh laanh Yietc hnyangx

1 2 3 4 5 6 7 8

Aengx maaih nyei mienh laanh:

CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Adult Care)

May 2011 CACFP Meal Benefit Income Eligibility Adult Care Form

Page 1 of 2 - Mien

Part 1. Yietc zungv biauv zong mienh laanh

Yietc zungv domh mienh nyei mbuox, dongh bieqc domh mienh nyei gorn wuov deix:

Domh mienh nyie mbuo, dongh bieqc domh mienh nyei gorn wuov deix: (First, Middle Initial, Last)

KITC SE GORNGV MAIV MAAIH NYAANH HLAAX

Part 2. Hungh jaa nyaanh: Se gorngv haaix dauh yiem biauv zong duqv , , , fai nor, fiev jienv ninh mbuox caux ninh “case number” oc. Se gorngv maiv maaih haaix dauh duqv naaiv kang nyaanh nor, nqenx mingh taux part 3. MBUOX:_________________________________________________ CASE NUMBER: _________________________________

Part 3. Yietc zungv biauv zong nyei nyaanh hlaax, liemh jienv nzou funx nyei nyaanh hlaax (gross income)—Meih yaac oix zuqc mbuox yie mbuo meih duqv mbuoqc ziex caux ndongc haaix maqc.

B. Liemh nzou nyei nyaanh hlaax caux duqv ndongc haaix maqc.

A. Mbuox (Kungx fiev dongh naaiv dauh fai naaiv deix domh mienh nyei mbuox caux ninh nyei auv-nqox caux jienv yietc zungv dongh corc caux ninh mbuo yiem wuov deix fu’jueiv.

1. Gong-zinh dongh maiv gaengh jaamv cuotv

2. Welfare, fu’jueiv nyei support, auv-nqox nyei support.

3. Pensions, retirement, Social Security, SSI, VA nyei nyaanh hlaax

4. Yietc Zungv Dieh Nyungc Nyei Nyaanh Hlaax

(Beiv hnangv) Jane Smith $200/ leiz-baaix _____ $150/ nqaeqv norm leiz-baaix_ $100/ yietc hlaax__________ $______/________

$ $ $ $

$ $ $ $

$ $ $ $

$ $ $ $

Part 4. Senh Jienv Mbuox Caux Nqa’haav Laai Wuov Deix Biei Norm “Social Number” (Domh Mienh Oix Zuqc Senh)

Domh mienh yiem biauv zong oix zuqc senh jienv mbuox njiec naaiv zeiv formh. Se gorngv Part 3 se fiuh dorng nor, dongh wuov laanh domh mienh senh naaiv zeiv formh naaiv oix zuqc fiev jienv ninh nyei nqa’haav-laai wuov deix biei norm Social Number fai kitc jienv wuov norm qongx dongh gorngv “Yie maiv maaih Social number” wuov qongx. (Mbienv naaiv pin zeiv nzuonx nqa'haav nqaang mangc ninh mbuo nyei leiz oc.)

Yie laengz gorngv yietc zungv yie fiev njiec naaiv zeiv formh se zien nyei caux jienv yietc zungv nyaanh hlaax yaac fiev njiec nzengc mi’aqv. Yie bieqc hnyouv goux mangc mienh nyei gorn haih duqv zipv domh hungh jaa tengx nyaanh (Federal funds) weic yie fiev njiec nyei jauv. Yie bieqc hnyouv CACFP nyei gong-mienh maaih leiz dimv mangc dongh yie fiev njiec nyei. Yie bieqc hnyouv se gorngv yie baac-baac fiev jaav nyei jauv njiec nor, yie nyei fu’jueiv nziex maiv haih duqv hungh jaa tengx nyanc hopv, liuz yie yaac haih zuqc hungh jaa hoic. Senh mbuox: _________________________________________________ Fiev mbuox:__________________________________________________

Hnoi:________________________________________________________

Dorngx yiem: _________________________________________________ Phone Number: _______________________________________________

Mungv: ______________________________________________________ Saengv: ____________________ Zip Code: _______________________

Nqa’haav-laai wuov deix biei norm Social Number: * * * - * * - ___ ___ ___ ___ Yie maiv maaih Social Number

Part 5. Fu’jueiv nyei fingx (dau yaac longx nyei)

Ginv norm fingx: Ginv norm fai i norm fingx:

Hispanic fai Latino

Maiv zeiz Hispanic fai Latino

E^sie Aa^me^li^gaa Indian fai Alaska nyei janx

Janx-Baeqc Hawaii nyei janx fai ganh fingx koiv-nzou (island) nyei janx

Janx-jieqv fai Aa^me^li^gaa nyei Aa^fi^gaa

CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Adult Care)

May 2011 CACFP Meal Benefit Income Eligibility Adult Care Form

Page 2 of 2 - Mien

Maiv dungx fiuh naaiv nqanx. Naaiv bun ninh mbuo nyei dorngh fiuh hnangv.

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12

Total Income: ____________ Per: Week, Every 2 Weeks, Twice A Month, Month, Year Household size: _________

Categorical Eligibility: ___ Date Withdrawn: ________ Eligibility: Free___ Reduced___ Denied___ Tier I_____ Tier II____

Reason: _____________________________________________________________________________________________________

Temporary: Free_____ Reduced_____ Time Period: ______________________________(expires after _____ days)

Determining Official’s Signature: _______________________________________________________________ Date: ______________

Confirming Official’s Signature: ________________________________________________________________ Date: ______________

Follow-up Official’s Signature: _________________________________________________________________ Date:______________

Meih nyei fu’jueiv nziex haih duqv nyanc kungx fai zuqc cuotv buonc jaax-zinh se gorngv meih nyei biauv zong nyei nyaanh hlaax duqv mbuoqc fai gauh nzoqc yiem naaiv norm qongx duqv fiev njiec daaih nyei.

Richard B. Russell Horqc Dorngh Nyanc Hopv Nyei Domh Leiz (Richard B. Russell National School Lunch Act) dingc daaih formh oix zuqc duqv zipv hiuv naaiv deix jauv. Meih maiv zuqc taan taux meih nyei jauv bun yie mbuo, mv baac se gorngv meih maiv zoux nor, yie mbuo yaac maiv haih tengx meih nyei fu’jueiv nyanc kungx fai cuotv buonc jaax-zinh. Se gorngv meih nyei fu’jueiv fai hungh jaa liuc leiz nyei fu’jueiv duqv Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program fai Food Distribution Program on Indian Reservations (FDPIR) maaih jienv (FDPIR) “case number” fai ganh nyungc porv mengh gorngv domh mienh senh naaiv zeiv formh se maiv maaih Social Security Number. Yie mbuo longc meih fiev njiec nyei jauv zaah mangc gaax meih horpc zuqc duqv fai maiv duqv hungh jaa tengx nyanc kungx fai cuotv buonc jaax zinh, aengx caux bun gong-mienh maaih leiz longc weic tengx zangv gorn.

Longc Baengh Leiz (non-discrimination): Naaiv deix waac njaaux taux oix zuqc hnangv haaix nor zoux se gorngv meih hnamv daaih mienh ki zuqc meih. “Ei Domh Hungh Jaa Nyei Doz-Leiz (Federal Law and U.S. Department of Agriculture Policy), maiv yuangh naaiv norm gorn ki haaix dauh weic ninh nyei fingx, ninh nyei setv, yiem ganh norm deic-bung daaih, benx m’jangc fai m’sieqv, hnyangx-jeiv lunx fai gox, fai waaic fangx. Se gorngv meih oix gox zongc mienh longc leiz maiv baengh nor, tov fiev fienx mingh bun USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 fai heuc kungx (866) 632-9992 (Gorngv waac). Haaix dauh m’normh maiv mbienc fai gorngv waac maiv junh nor, longc Federal Relay Service (800) 877-8339; fai (800) 845-6136 (Spanish) heuc USDA yaac duqv nyei. USDA benx longc baengh leiz tengx mingh nyei gorn yaac zeiz longc baengh leiz nyei gong-ziouv.”

Biauv zong mienh laanh Yietc hnyangx

1 2 3 4 5 6 7 8

Aengx maaih nyei mienh laanh:

May 2011 CACFP Meal Benefit Income Eligibility Form Letter of Verification (Child)

Page 2 of 2 - Mien

Meih oix zuqc fungx naaiv deix sou dongh yie mbuo za’gengh qiemx zuqc longc nyei wuov, fai heuc mingh [name] ja’ndaangc [date], maiv zeiz nor, yie mbuo nyei goux fu’jueiv nyei gorn maiv haih duqv hung jaa tengx bun meih nyei fu’jueiv duqv nyanc fungx fai tengx cuotv buonc jaax zinh oc. Gorn/Nzie nyei gorn [ Name _] [Date] Tong Taux [Name]:

Yie mbuo zaah mangc meih nyei CACFP Duqv Tengx Fai Maiv Duqv nyei Nyanc Hopv Formh. Yie mbuo oix zuqc zaanh longx nyei gorngv haaix dauh se horpc zuqc duqv CACFP tengx. Meih oix zuqc fungx deix sou daaih tengx zoux zorng-zengx gorngv naaiv dauh mienh [name(s) of participant(s)] gengh zien duqv tengx nyei oc .

Duqv nor, fungx zeiv dongh yienz cuotv daaih nyei sou, maiv zeiz zien wuov zeiv oc. Se gorngv meih fungx zien wuov zeiv fienx nor, meih maiv duqv daux nqaang, cuotv liuz meih mbuox bun duqv hiuv gorngv meih oix longc daux nqaang oc. Maiv dungx fungx meih nyei EBT card fai ganh nyungc nyaanh nyei pienx (card) dongh meih zanc-zanc oix zuqc longc wuov oc. 1. Se gorngv meih duqv hungh jaa tengx SNAP], TANF fai FDPIR nor, dongh meih fiuh naaiv deix formh nyei ziangh hoc, yienz cuotv (copy) zeiv ga’ndiev naaiv deix fienx daaih fungx bun yie mbuo oc.

• SNAP, TANF fai FDPIR nyei fienx dongh gorngv meih haaix zanc duqv hungh jaa tengx naaiv kang nyaanh wuov oc. • SNAP fai Welfare dorngh nyei fienx dongh gorngv meih duqv hungh jaa tengx SNAP fai TANF mi’aqc wuov oc. 2. Se gorngv meih duqv naaiv zeiv fienx mv baac naaiv dauh fu’jueiv se benx hungh jaa liuc leiz nyei fu’jueiv (foster child)nor:

Fungx gorn fai sic dorngh nyei fienx dongh maaih jienv gorngv haaix dauh haih tengx duqv yie mbuo dimv sou-gorn mangc gorngv naaiv dauh fu’jueiv za’gengh zien benx hungh jaa tengx liuc leiz nyei fu’jueiv wuov oc.

3. Se gorngv meih maiv duqv hungh jaa tengx SNAP, TANF fai FDPIR nor: Fungx jienv naaiv pin (this page) fienx caux jienv meih nyei fienx dongh gorngv meih nyei biauv zong nyaanh hlaax se duqv mbuoqc zeix yaac duqv yiem haaix daaih. Fienx yaac oix zuqc maaih jienv naaiv dauh mienh nyei mbuox, caux dongh haaix hnoi, aengx caux jienv duqv mbuoqc zeix, yaac duqv ndongc haaix maqc. Fungx naaiv deix sou mingh bun: [address].

Maaih leiz zipv nyei fienx se dongh naaiv: Gong: Gong nyei nyaanh piux dueiv (Paycheck stub) fai maaih jienv fienx-mbuoqc gorngv duqv nyaanh hlaax mbuoqc ziex caux duqv ndongc haaix maqc; fai maaih jienv fienx gorngv gong-ziouv laengz bun mbuoqc ziex dongh liemh jienv nzou nyei buonc caux duqv ndongc haaix maqc; se gorngv meih nyei gong se meih nyei saeng-eix fai zoux ndeic nor, fungx dongh meih zornc duqv mbuoqc ziex caux longc cuotv mbuoqc ziex wuov deix sou. Social Security nyaanh, jiex daaih tengx zoux gong nyei nyaanh (Pensions), fai dingh gong nyaanh: Fungx Social Security dingh gong nyaanh nyei sou, dongh gorngv duqv mbuoqc zeiz, fai jiex daaih tengx zoux gong nyei nyaanh nyei sou. Ndortv gong nyaanh, Mienh waaic nyaanh, fai zoux gong mun nyei nyaanh: Bun dongh gorngv hungh jaa fai gong-ziouv yietc hlaax bun mbuoqc ziex meih wuov zeiv fienx. Se gorngv duqv zoux gong mun nyei nyaanh nor, fungx dongh office fungx bun meih wuov zeiv fienx. Welfare nyaanh: Fungx dongh hungh jaa bun daaih gorngv meih se duqv “welfare” wuov zeiv fienx. Fu’jueiv nyei support fai auv-nqox nyei support nyaanh: Fungx sic dorngh nyei fienx (Court decree) dongh gorngv laengz bun meih mbuoqc ziex, fai dongh meih duqv liuz nyei nyaanh check meih yienz cuotv wuov (copies of checks received). Ganh bung nyaanh (hnangv meih maaih biauv saauh bun mienh yiem nyei nyaanh): Fungx wuov zeiv fienx dongh gorngv duqv mbuoqc ziex nyaanh caux duqv ndongc haaix maqc. Fienx yaac oix zuqc maaih jienv hnoi. Maiv maaih nyaanh hlaax: Fiev zeiv fienx daaih porv mengh gorngv meih hnangv haaix nor haih tengx biauv zong lorz nyanc hopv, lorz lui-houx, caux maaih biauv bun ninh mbuo yiem, aengx caux jienv meih haaix zanc cingx maaih nyaanh hlaax. Military Housing Privatization Initiative: Fungx hungh jaa nyei fienx fai saauh dorngx yiem nyei fienx dongh gorngv meih nyei biauv se hungh jaa tengx cuotv weic meih zoux baeng (Military Privatized Housing Initiative).

May 2011 CACFP Meal Benefit Income Eligibility Form Letter of Verification (Child)

Page 2 of 2 - Mien

Zianh hoc bun zipv nyaanh hlaax nyei sou: Tov fungx sou daaih bun mangc gorngv dongh meih fiuh jienv naaiv zeiv formh nyei ziangh hoc naaiv, meih nyei nyaanh hlaax se duqv mbuoqc zeix. Se gorngv meih ih zanc maiv hiuv nor yaac maiv benx haaix nyungc, mv baac oix zuqc fungx ndaangc dongh yie mbuo oix zuqc dimv naaiv zeiv CACFP formh nyei ziangh hoc oc.

Se gorngv maaih haaix nyungc waac naaic fai qiemx zuqc tengx nor, heuc mingh [name] [phone number]. Ziepc Zuoqc Hnyouv, [signature] Richard B. Russell Horqc Dorngh Nyanc Hopv Nyei Domh Leiz (Richard B. Russell National School Lunch Act) dingc daaih formh oix zuqc duqv zipv hiuv naaiv deix jauv. Meih maiv zuqc taan taux meih nyei jauv bun yie mbuo, mv baac se gorngv meih maiv zoux nor, yie mbuo yaac maiv haih tengx meih nyei fu’jueiv nyanc kungx fai cuotv buonc jaax-zinh. Meih oix zuqc fiev njiec dauh dauh domh mienh nyei nqa’haav laai wuov deix bieiv norm “social number” aengx caux jienv naaiv dauh fu’jueiv nyei oc. Se gorngv meih tengx hungh jaa liuc leiz nyei fu’jueiv fiuh naaiv zeiv formh nor, maiv zuqc fiev njiec ninh nyei social number oc, fai meih fu’jueiv duqv Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program fai Food Distribution Program on Indian Reservations (FDPIR) maaih jienv (FDPIR) “case number” fai ganh nyungc porv mengh gorngv domh mienh senh naaiv zeiv formh se maiv maaih Social Security Number. Yie mbuo longc meih fiev njiec nyei jauv zaah mangc gaax meih horpc zuqc duqv fai maiv duqv hungh jaa tengx nyanc kungx fai cuotv buonc jaax zinh, aengx caux bun gong-mienh maaih leiz longc weic tengx zangv CACFP.

Longc Baengh Leiz: Naaiv deix waac njaaux taux oix zuqc hnangv haaix nor zoux se gorngv meih hnamv daaih mienh ki zuqc meih. “Ei Domh Hungh Jaa Nyei Doz-Leiz (Federal Law and U.S. Department of Agriculture Policy), maiv yuangh naaiv norm gorn ki haaix dauh weic ninh nyei fingx, ninh nyei setv, yiem ganh norm deic-bung daaih, benx m’jangc fai m’sieqv, hnyangx-jeiv lunx fai gox, fai waaic fangx. Se gorngv meih oix gox zongc mienh longc leiz maiv baengh nor, tov fiev fienx mingh bun USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 fai heuc kungx (866) 632-9992 (Gorngv waac). Haaix dauh m’normh maiv mbienc fai gorngv waac maiv junh nor, longc Federal Relay Service (800) 877-8339; fai (800) 845-6136 (Spanish) heuc USDA yaac duqv nyei. USDA benx longc baengh leiz tengx mingh nyei gorn yaac zeiz longc baengh leiz nyei gong-ziouv.”

May 2011 CACFP Meal Benefit Income Eligibility Form Letter of Verification (Adult)

Page 1 of 2 - Mien

Meih oix zuqc fungx naaiv deix sou daaih bun, weic zuqc yie mbuo za’gengh qiemx zuqc longc, fai nor heuc mingh [name] ja’ndaangc [date], fai nor yie mbuo nyei gorn ziouc maiv duqv hungh jaa tengx nyanc kungx fai tengx cuotv buonc jaax zinh domh mienh nyanc hopv nyei jauv. Gorn/Nzie gorn: [ Name _] [Date] Tong taux [Name]:

Yie mbuo zaah mangc meih nyei CACFP Duqv Tengx Fai Maiv Duqv nyei Nyanc Hopv Formh. Yie mbuo oix zuqc zaanh longx nyei gorngv haaix dauh se horpc zuqc duqv CACFP tengx. Meih oix zuqc fungx deix sou daaih tengx zoux zorng-zengx gorngv naaiv dauh mienh [name(s) of participant(s)] gengh zien duqv tengx nyei oc .

Duqv nor, fungx zeiv dongh yienz cuotv daaih nyei sou, maiv zeiz zien wuov zeiv oc. Se gorngv meih fungx zien wuov zeiv fienx nor, meih maiv duqv daux nqaang, cuotv liuz meih mbuox bun duqv hiuv gorngv meih oix longc daux nqaang oc. Maiv dungx fungx meih nyeiEBT card fai ganh nyungc nyaanh nyei pienx (card) dongh meih zanc-zanc oix zuqc longc wuov oc.

1. Se gorngv meih duqvSNAP, FDPIR, SSI fai Medicaid dongh meih fiuh tov nyanc kungx fai tengx cuotv buonc jaax zingh nyei ziangh hoc, fai yiem dongh meih fiuh liuz formh nyei ziangh hoc nor, yienz zeiv naaiv deix sou fungx daaih bun yie mbuo oc.

• SNAP, FDPIR, SSI fai Medicaid nyei fienx dongh gorngv meih haaix zanc duqv hungh jaa tengx meih wuov oc. • SNAP nyei fienx dongh gorngv meih duqv hungh jaa tengx SNAP mi’aqc wuov oc..

2. Se gorngv meih maiv duqv SNAP, FDPIR, SSI fai Medicaid nor: Fungx jienv naaiv pin (this page) fienx caux jienv meih nyei fienx dongh gorngv meih nyei biauv zong nyaanh hlaax se duqv mbuoqc zeix yaac duqv yiem haaix daaih. Fienx yaac oix zuqc maaih jienv naaiv dauh mienh nyei mbuox, caux dongh haaix hnoi, aengx caux jienv duqv mbuoqc zeix, yaac duqv ndongc haaix maqc. Fungx naaiv deix sou mingh bun: [address].

Maaih leiz zipv nyei fienx se dongh naaiv: Gong: Gong nyei nyaanh piux dueiv (Paycheck stub) fai maaih jienv fienx-mbuoqc gorngv duqv nyaanh hlaax mbuoqc ziex caux duqv ndongc haaix maqc; fai maaih jienv fienx gorngv gong-ziouv laengz bun mbuoqc ziex dongh liemh jienv nzou nyei buonc caux duqv ndongc haaix maqc; se gorngv meih nyei gong se meih nyei saeng-eix fai zoux ndeic nor, fungx dongh meih zornc duqv mbuoqc ziex caux longc cuotv mbuoqc ziex wuov deix sou. Social Security nyaanh, jiex daaih tengx zoux gong nyei nyaanh (Pensions), fai dingh gong nyaanh: Fungx Social Security dingh gong nyaanh nyei sou, dongh gorngv duqv mbuoqc zeiz, fai jiex daaih tengx zoux gong nyei nyaanh nyei sou. Ndortv gong nyaanh, Mienh waaic nyaanh, fai zoux gong mun nyei nyaanh: Bun dongh gorngv hungh jaa fai gong-ziouv yietc hlaax bun mbuoqc ziex meih wuov zeiv fienx. Se gorngv duqv zoux gong mun nyei nyaanh nor, fungx dongh office fungx bun meih wuov zeiv fienx. Welfare nyaanh: Fungx dongh hungh jaa bun daaih gorngv meih se duqv “welfare” wuov zeiv fienx. Fu’jueiv nyei support fai auv-nqox nyei support nyaanh: Fungx sic dorngh nyei fienx (Court decree) dongh gorngv laengz bun meih mbuoqc ziex, fai dongh meih duqv liuz nyei nyaanh check meih yienz cuotv wuov (copies of checks received). Ganh bung nyaanh (hnangv meih maaih biauv saauh bun mienh yiem nyei nyaanh): Fungx wuov zeiv fienx dongh gorngv duqv mbuoqc ziex nyaanh caux duqv ndongc haaix maqc. Fienx yaac oix zuqc maaih jienv hnoi. Maiv maaih nyaanh hlaax: Fiev zeiv fienx daaih porv mengh gorngv meih hnangv haaix nor haih tengx biauv zong lorz nyanc hopv, lorz lui-houx, caux maaih biauv bun ninh mbuo yiem, aengx caux jienv meih haaix zanc cingx maaih nyaanh hlaax. Military Housing Privatization Initiative: Fungx hungh jaa nyei fienx fai saauh dorngx yiem nyei fienx dongh gorngv meih nyei biauv se hungh jaa tengx cuotv weic meih zoux baeng (Military Privatized Housing Initiative).

May 2011 CACFP Meal Benefit Income Eligibility Form Letter of Verification (Adult)

Page 2 of 2 - Mien

Zianh hoc bun zipv nyaanh hlaax nyei sou: Tov fungx sou daaih bun mangc gorngv dongh meih fiuh jienv naaiv zeiv formh nyei ziangh hoc naaiv, meih nyei nyaanh hlaax se duqv mbuoqc zeix. Se gorngv meih ih zanc maiv hiuv nor yaac maiv benx haaix nyungc, mv baac oix zuqc fungx ndaangc dongh yie mbuo oix zuqc dimv naaiv zeiv CACFP formh nyei ziangh hoc oc.

Se gorngv maaih haaix nyungc waac naaic fai qiemx zuqc tengx nor, heuc mingh [name] [phone number]. Ziepc Zuoqc Hnyouv, [signature] Richard B. Russell Horqc Dorngh Nyanc Hopv Nyei Domh Leiz (Richard B. Russell National School Lunch Act) dingc daaih formh oix zuqc duqv zipv hiuv naaiv deix jauv. Meih maiv zuqc taan taux meih nyei jauv bun yie mbuo, mv baac se gorngv meih maiv zoux nor, yie mbuo yaac maiv haih tengx meih nyei fu’jueiv nyanc kungx fai cuotv buonc jaax-zinh. Se gorngv meih nyei fu’jueiv fai hungh jaa liuc leiz nyei fu’jueiv duqv Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program fai Food Distribution Program on Indian Reservations (FDPIR) maaih jienv (FDPIR) “case number” fai ganh nyungc porv mengh gorngv domh mienh senh naaiv zeiv formh se maiv maaih Social Security Number. Yie mbuo longc meih fiev njiec nyei jauv zaah mangc gaax meih horpc zuqc duqv fai maiv duqv hungh jaa tengx nyanc kungx fai cuotv buonc jaax zinh, aengx caux bun gong-mienh maaih leiz longc weic tengx zangv gorn. Longc Baengh Leiz: Naaiv deix waac njaaux taux oix zuqc hnangv haaix nor zoux se gorngv meih hnamv daaih mienh ki zuqc meih. “Ei Domh Hungh Jaa Nyei Doz-Leiz (Federal Law and U.S. Department of Agriculture Policy), maiv yuangh naaiv norm gorn ki haaix dauh weic ninh nyei fingx, ninh nyei setv, yiem ganh norm deic-bung daaih, benx m’jangc fai m’sieqv, hnyangx-jeiv lunx fai gox, fai waaic fangx. Se gorngv meih oix gox zongc mienh longc leiz maiv baengh nor, tov fiev fienx mingh bun USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 fai heuc kungx (866) 632-9992 (Gorngv waac). Haaix dauh m’normh maiv mbienc fai gorngv waac maiv junh nor, longc Federal Relay Service (800) 877-8339; fai (800) 845-6136 (Spanish) heuc USDA yaac duqv nyei. USDA benx longc baengh leiz tengx mingh nyei gorn yaac zeiz longc baengh leiz nyei gong-ziouv.”

WE HAVE CHECKED YOUR CACFP MEAL BENEFIT

INCOME ELIGIBILITY FORM INFORMATION (Child Care)

May 2011 CACFP Meal Benefit Income Eligibility Form Letter of Verification Results (Child) (Pricing programs only) Page 1 of 1 - Mien

Gorn fai gorn nyei mienh: [ Name ] [ Date: ]

Tong taux [ Name ]:

Yie mbuo duqv dimv mangc meih nyei formh dongh meih duqv tengx fiuh weic [name(s) of child(ren)] mangc gaax ninh se duqv nyanc kungx fai zuqc cuotv buonc jaax-zinh liuz yie mbuo dingc daaih:

Ninh duqv nyei wuov daaih maiv zuqc tiuv.

Yiem naaiv [date], dongh ninh zuqc cuotv buonc jaax-zinh tiuv mingh nyanc kungx weic zuqc mangc liuz nyaanh hlaax maiv jiex ndaangc ninh mbuo nyei soux (limit.) Meih nyei fu’jueiv ziouc duqv nyanc kungx, maiv zuqc maaiz.

Jiex gorn [date], meih nyei fu’jueiv nyei nyanc hopv dongh duqv nyanc kungx , ih zanc tiuv mingh zuqc cuotv buonc jaax-zinh weic zuqc meih nyei biauv zong nyaanh hlaax se jiex ndaangc ninh mbuo nyei soux (limit.)

Jiex gorn [date], meih nyei fu’jueiv se maiv duqv hungh jaa tengx bun nyanc kungx fai duqv cuotv buonc jaax-zinh aqv weic zuqc naaiv diuc fai naaiv deix jauv: ___ Sou-gorn maiv maaih gorngv haaix dauh yiem meih nyei biauv zong duqv SNAP, FDPIR, SSI, or Medicaid nyei

hungh jaa nyaanh. ___ Sou-gorn maiv maaih gorngv fu’jueiv se benx njiouh huaax, biaux domh mienh, fai benx gong-torngx (migrant). ___ Meih nyei nyaanh hlaax jiex ndaangc ninh mbuo nyei soux (limit) dongh haih tengx duqv zuqc nyanc kungx fai cuotv

buonc jaax-zinh wuov. ___ Meih maiv bun:______________________________________________________________________________ ___ Meih maiv dau yie mbuo nyei waac (request).

Se gorngv meih nyei nyaanh hlaax duqv nzoqc njiec fai camv faaux, fai meih nyei biauv zong mienh laanh camv faaux nor, meih aengx haih fiuh duqv nzunc naaiv CACFP zeiv nyanc hopv formh nyei. Mv baac se gorngv aengx fiuh nzunc nor meih yaac maiv bun jienv sou zoux zorng zengx nor, yie mbuo yaac oix zuqc naaic lorz nyei.

Se gorngv meih haiz maiv horpc hnyouv nor, meih maaih leiz heuc mingh caux [name] [phone] gorngv oc. Meih yaac maaih leiz mingh lorz mienh tengx muangx sic nyei. Se gorngv meih oix lorz hnoi daaih muangx sic nor, oix zuqc mbuox ndaangc naaiv norm hnoi [date], meih nyei fu’jueiv corc duqv nyanc kungx fai zuqc cuotv buonc jaax-zinh taux paaiv sic nyei mienh dingc daaih. Meih oix lorz mienh tengx muangx sic nor heuc mingh naaiv norm number fai fiev fienx bun [name], [address], [phone number], fai [e-mail]. Ziepc Zuoqv Hnyouv, [signature] Longc Baengh Leiz: Naaiv deix waac njaaux taux oix zuqc hnangv haaix nor zoux se gorngv meih hnamv daaih mienh ki zuqc meih. “Ei Domh Hungh Jaa Nyei Doz-Leiz (Federal Law and U.S. Department of Agriculture Policy), maiv yuangh naaiv norm gorn ki haaix dauh weic ninh nyei fingx, ninh nyei setv, yiem ganh norm deic-bung daaih, benx m’jangc fai m’sieqv, hnyangx-jeiv lunx fai gox, fai waaic fangx. Se gorngv meih oix gox zongc mienh longc leiz maiv baengh nor, tov fiev fienx mingh bun USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 fai heuc kungx (866) 632-9992 (Gorngv waac). Haaix dauh m’normh maiv mbienc fai gorngv waac maiv junh nor, longc Federal Relay Service (800) 877-8339; fai (800) 845-6136 (Spanish) heuc USDA yaac duqv nyei. USDA benx longc baengh leiz tengx mingh nyei gorn yaac zeiz longc baengh leiz nyei gong-ziouv.”

WE HAVE CHECKED YOUR CACFP MEAL BENEFIT

INCOME ELIGIBILITY FORM INFORMATION (Adult Care)

May 2011 CACFP Meal Benefit Income Eligibility Form Letter of Verification Results (Adult) (Pricing programs only) Page 1 of 1 - Mien

Gorn/Nzie nyei gorn: [ Name ] [ Date: ] Tong Taux [ Name ]:

Yie mbuo duqv dimv mangc meih nyei formh dongh meih duqv tengx fiuh weic [name(s) of child(ren)] mangc gaax ninh se duqv nyanc kungx fai zuqc cuotv buonc jaax-zinh liuz yie mbuo dingc daaih:

Ninh duqv nyei wuov daaih maiv zuqc tiuv.

Yiem naaiv [date], dongh ninh zuqc cuotv buonc jaax-zinh tiuv mingh nyanc kungx weic zuqc mangc liuz nyaanh hlaax maiv jiex ndaangc ninh mbuo nyei soux (limit.) Meih nyei fu’jueiv ziouc duqv nyanc kungx, maiv zuqc maaiz.

Jiex gorn [date], meih nyei fu’jueiv nyei nyanc hopv dongh duqv nyanc kungx , ih zanc tiuv mingh zuqc cuotv buonc jaax-zinh weic zuqc meih nyei biauv zong nyaanh hlaax se jiex ndaangc ninh mbuo nyei soux (limit.)

Jiex gorn [date], meih nyei fu’jueiv se maiv duqv hungh jaa tengx bun nyanc kungx fai duqv cuotv buonc jaax-zinh aqv weic zuqc naaiv diuc fai naaiv deix jauv: ___ Sou-gorn maiv maaih gorngv haaix dauh yiem meih nyei biauv zong duqv SNAP, FDPIR, SSI, or Medicaid nyei

hungh jaa nyaanh. ___ Sou-gorn maiv maaih gorngv fu’jueiv se benx njiouh huaax, biaux domh mienh, fai benx gong-torngx (migrant). ___ Meih nyei nyaanh hlaax jiex ndaangc ninh mbuo nyei soux (limit) dongh haih tengx duqv zuqc nyanc kungx fai cuotv

buonc jaax-zinh wuov. ___ Meih maiv bun:______________________________________________________________________________ ___ Meih maiv dau yie mbuo nyei waac (request).

Se gorngv meih nyei nyaanh hlaax duqv nzoqc njiec fai camv faaux, fai meih nyei biauv zong mienh laanh camv faaux nor, meih aengx haih fiuh duqv nzunc naaiv CACFP zeiv nyanc hopv formh nyei. Mv baac se gorngv aengx fiuh nzunc nor meih yaac maiv bun jienv sou zoux zorng zengx nor, yie mbuo yaac oix zuqc naaic lorz nyei.

Se gorngv meih haiz maiv horpc hnyouv nor, meih maaih leiz heuc mingh caux [name] [phone] gorngv oc. Meih yaac maaih leiz mingh lorz mienh tengx muangx sic nyei. Se gorngv meih oix lorz hnoi daaih muangx sic nor, oix zuqc mbuox ndaangc naaiv norm hnoi [date], meih nyei fu’jueiv corc duqv nyanc kungx fai zuqc cuotv buonc jaax-zinh taux paaiv sic nyei mienh dingc daaih. Meih oix lorz mienh tengx muangx sic nor heuc mingh naaiv norm number fai fiev fienx bun [name], [address], [phone number], fai [e-mail]. Ziepc Zuoqv Hnyouv, [signature] Longc Baengh Leiz: Naaiv deix waac njaaux taux oix zuqc hnangv haaix nor zoux se gorngv meih hnamv daaih mienh ki zuqc meih. “Ei Domh Hungh Jaa Nyei Doz-Leiz (Federal Law and U.S. Department of Agriculture Policy), maiv yuangh naaiv norm gorn ki haaix dauh weic ninh nyei fingx, ninh nyei setv, yiem ganh norm deic-bung daaih, benx m’jangc fai m’sieqv, hnyangx-jeiv lunx fai gox, fai waaic fangx. Se gorngv meih oix gox zongc mienh longc leiz maiv baengh nor, tov fiev fienx mingh bun USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 fai heuc kungx (866) 632-9992 (Gorngv waac). Haaix dauh m’normh maiv mbienc fai gorngv waac maiv junh nor, longc Federal Relay Service (800) 877-8339; fai (800) 845-6136 (Spanish) heuc USDA yaac duqv nyei. USDA benx longc baengh leiz tengx mingh nyei gorn yaac zeiz longc baengh leiz nyei gong-ziouv.”

SHARING INFORMATION WITH MEDICAID/SCHIP

May 2011 CACFP Meal Benefit Income Eligibility Form Sharing Information with Medicaid/SCHIP

Page 1 of 1 - Mien


Se gorngv meih nyei fu’jueiv yiem horqc dorngh duqv nyanc kungx fai zuqc cuotv buonc nyanc hopv nyei jaax zinh nor, ninh mbuo yaac nziex haih duqv Medicaid tengx kungx fai cuotv buonc jaax-zinh maaiz Medicaid fai State Children's Health Insurance Program (SCHIP). Fu’jueiv dongh maaih (health insurance) gauh duqv mingh buangh ndie-sai maqc yaac gauh wangc siangx, maiv zuqc guangc maiv mingh doqc sou weic laaix butv wuon-baengc.

Weic zuqc “health insurance” so longc jienv haic bun fu’jueiv nyei buonh sin, cuotv liuz meih maiv oix yie mbuo mbuox nor, hungh jaa bun yie mbuo maaih leiz mbuox Medicaid caux SCHIP gorngv se meih nyei fu’jueiv duqv nyanc kungx fai zuqc cuotv buonc jaax-zinh, Medicaid caux SCHIP se kungx longc meih fiev njiec nyei jauv dimv mangc gaax fu’jueiv haih duqv bieqc naaiv deix gorn nyei fai hnangv. Gorn nyei gong-mienh nzunc baav haih mbuox taux meih gorngv meih nyei fu’jueiv se haih duqv hungh jaa tengx naaiv deix program nyei. Meih fiuh naaiv deix nyanc hopv nyei formh naaiv yaac maiv ziang wuov la’guaih haih bun meih nyei fu’jueiv duqv “health insurance”.

Se gorngv meih maiv oix bun Medicaid fai SCHIP, hiuv taux meih fiev njiec nyei jauv nor, fiuh jienv ga’ndiev naaiv nqanx formh liuz fungx nzuonx oc (fungx naaiv nqanx formh se maiv maaih buonc haih tiuv gorngv meih nyei fu’jueiv duqv nyanc kungx fai zuqc cuotv buonc jaax-zinh).

Maiv Dungx! Yie maiv oix yie nyei fienx tong taux Medicaid fai (State Children's Health Insurance Program).

Se gorngv meih kitc maiv dungx, fiuh jienv ga’ndiev naaiv nqanx form oc. Fu’jueiv nyei mbuox: ________________________________________________________________________________

Fu’jueiv nyei mbuox: ________________________________________________________________________________



Domh mienh fai goux nyei mienh senh mbuox: ___________________________________________________________

Ih Hnoi nyei hnoi: __________________________________________________________________________________

Fiev meih nyei mbuox: ______________________________________________________________________________

Dorngx yiem: ______________________________________________________________________________________

______________________________________ ________________________________________________________

Oix hiuv gauh muonc nor, meih heuc mingh [name] at [phone]

child and adult care food program · pdf filechild and adult care food program ... [name,...

Documents