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Updated Eligibility Forms for Adult Care Agencies

Nutrition Services Division Management Bulletin
Purpose: Policy, Beneficial Information

To: Child and Adult Care Food Program Adult Care Sponsors

Number: NSD-CACFP-07-2012

Attention: Authorized Representatives and Program Directors

Date: April 2012

Subject: Updated Eligibility Forms for Adult Care Agencies

Reference: Title 7, Code of Federal Regulations, Part 226.23(e)

This Management Bulletin (MB) notifies Child and Adult Care Food Program (CACFP) Adult Care Center sponsors that the California Department of Education (CDE) has simplified and updated eligibility template forms. The CDE encourages agencies currently using CDE-provided template forms to immediately begin using these updated versions.


In order to claim meals at the free and reduced-price reimbursement rates in the CACFP, the CDE requires agencies to retain documentation verifying participants’ free or reduced-price eligibility. These documentation requirements are described in Title 7, Code of Federal Regulations, Part 226.23(e).

In order to assist agencies in collecting this information, the CDE provides several template forms for agencies’ use.

Updated Forms

The forms described below are available at the CDE CACFP Adult Component Eligibility Materials Web page at and also in the Download Forms section of the Child Nutrition Information and Payment System (CNIPS).

Meal Benefit Form for Adult Participants

Agencies may use this form to document the eligibility of all participants. It replaces the previous template forms entitled Participation/Categorical Eligibility Application (NSD 7101A) and Participation/Income Eligibility Application (NSD 7101C).

Adult Letter to Households

Agencies must give a letter to participants when they distribute the Meal Benefit Form. The letter informs participants that the center participates in the CACFP offered by the U.S. Department of Agriculture (USDA) and serves meals at no separate charge to eligible enrolled adults. The CDE has updated the letter to include the current eligibility scale.

Adult Agency Enrollment/Eligibility Roster

Agencies may use the Adult Agency Enrollment/Eligibility Roster to document the enrollment and eligibility of participants as part of the one-month eligibility study required each October.

Agencies using the fixed percentage method of claiming reimbursement establish their fixed percentages for the entire year with the data reported from the one-month eligibility study in October. Agencies may change their fixed percentages, if desired, at any time during the year by completing another monthly eligibility study. Agencies using the actual count method of claiming reimbursement are required to conduct eligibility studies each month.

The roster replaces the previous template form entitled Participation/Categorical Eligibility Alternative Documentation (NSD 7101B).


If you have questions regarding using these forms to certify eligibility of participants, reporting changes in CACFP eligibility, or any other questions regarding this MB, you should contact the CACFP specialist assigned to your agency. You will find a list of contact information for specialists in the Download Forms section of the CNIPS.

Questions:   Nutrition Services Division | 800-952-5609
Last Reviewed: Tuesday, October 11, 2016
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