HOME INSTRUCTION for PARENTS of PRESCHOOL YOUNGSTERS FLORIDA HIPPY T&TA CENTER

HOME INSTRUCTION for PARENTS of PRESCHOOL YOUNGSTERS TANF Eligibility Form 2014-15 Please complete one form per HIPPY child. FAMILY DEMOGRAPHIC INFORMATION HIPPY Child Applying For HIPPY Services Gender (Select ONE): Name (Last, First): □ Male □ Female Race: Ethnicity: □American Indian or Alaskan Native □ Hispanic or Latino □Native Hawaiian or Other Pacific Islander □ Not Hispanic or Latino □ Asian □ Black or African American □ White □ Other: Social Security Number: Date of Birth (MM/DD/YYYY):

HIPPY Parent / Guardian: If the child is completing the HIPPY curriculum with an adult other than their parent, a signed and dated attestation from the parent describing the child’s care and living arrangements must be provided. Name (Last, First):

Relationship to HIPPY child: □Mother □ Father □ Grandmother □ Grandfather □ Aunt □ Uncle □ Stepmother □ Stepfather □ Foster Mother □ Foster Father □ Other: Address (Must match Street: FL Residency document) City: Zip Code:

Phone Number (Fill out completely – include area code): TANF ELIGIBILITY REQUIREMENTS Please provide a copy of ONE required document from each part to the Florida HIPPY T&TA Center

Part 1 – Parent Photo ID Part 2 – Florida Residency Part 3 – Child’s Citizenship Part 4 – Child’s Date of (include relationship to child Birth on document)  Florida Driver’s License  Florida Driver’s License  US Birth Certificate  Birth Certificate  Florida ID (NOT expired)  Other State Photo ID:  US Hospital Record  Immunization Record  Florida ID (NOT expired)  US Passport  Health Department  US Passport  Utility Bill Records  Religious documents recorded  Other Government Photo in the US shortly after birth  Bank Statement  Doctor’s Attestation ID:  Certificate of Citizenship or If NO Photo ID, provide 2 of  Insurance Policy Naturalization the following:  Social Security Card  Government Document  Lawfully admitted alien  Voter Registration Card with current address document (e.g. : Forms I-94,  Birth Record I-94A, I-197, I-1551, & I-766)  Other, please state: with non-US passport  Military Document  School Records

of 3 TANF ELIGIBILITY REQUIREMENTS CONTINUED **Please complete either Option A below or Option B on page 3, NOT BOTH.** □ Option A: Income Eligibility (Please provide documentation for ALL household Earned and Unearned income. Both earned and unearned income will be used to determine eligibility.) UNEARNED INCOME (Please check all that apply) □Social Security Administration □ Supplemental Security Income □ Unemployment Compensation □ Veteran Benefits □ Child support received □ Alimony support received □ Retirement Benefits □ Workers’ Compensation □ Other, including but not limited to: pensions, interest, awards, prizes, inheritances, dividends, royalties, proceeds from insurance policies, and or: $ Gross monthly amount (*from total on UNEARNED INCOME WORKSHEET) *Please complete UNEARNED INCOME WORKSHEET and enter amounts in space above. EARNED INCOME (Please choose ONE of the following) SIX WEEKS OF INCOME LETTER FROM EMPLOYER TAX RETURN NO INCOME

Pay stubs must be current Letter from employer must list Tax Return (prior year) Letter signed by and consecutive. □ □ □ the following: start date, rate of for self-employment* only parent(s) attesting that □ 6 Weekly Pay Stubs pay, and hours of work for and must include signature they have no household employee. (*Letter needs to be on or on-line signature #, earned or unearned 3 Bi-Weekly Pay Stubs □ employer’s letterhead and include annual gross income. income (*Letter must be □ 4 Semi-Monthly Pay Stubs employer’s EIN. If letterhead *If tax return includes verified and signed by the and/or EIN are not available then regular wages, please parent(s) and the □ 2 Monthly Pay Stubs include employer’s social security provide pay stubs or coordinator that the number.) letter from employer. household has NO income)

$ Gross monthly amount (*from total on EARNED INCOME WORKSHEET) or gross yearly amount for Tax Return ONLY *Please complete EARNED INCOME WORKSHEET and enter amounts in space above. ***DEDUCT ALIMONY PAID and CHILD SUPPORT PAID form TOTAL EARNED INCOME. You MUST include a document showing these payments or a letter signed and dated by the parent stating they make these payments. ***

Total of Total of UNEARNED INCOME + EARNED INCOME = $

PLEASE USE THIS TOTAL TO DETERMINE ELIGIBILITY BELOW Names of additional family members NOT listed on first page. 1) 2) 3) 4) 5) 6) 7) 8) 200% of the Federal Poverty Level (FPL) by family size (effective date: January 22, 2014) (For households larger than 8, add $676.66 per month or $8,120. per year for each additional household member)

Income Household Size and Family Income Household size 2 3 4 5 6 7 8 9 10

Monthly $2,621.67. $3,298.33 $3,975. $4,651.67 $5,328.33 $6,005. $6,681.67 $7,358.33 $8,035. Yearly $31,460. $39,580. $47,700. $55,820. $63,940. $72,060, $80,180. $88.300. $96,420. □ Family’s income is LESS THAN 200% of FPL and therefore IS TANF ELIGIBLE □ Family’s income is MORE THAN 200% of FPL and therefore IS NOT TANF ELIGIBLE I assure that the income information here represents ALL members of my household Parent’s initials: (including BOTH parents if living together in household).

of 3 TANF ELIGIBILITY REQUIREMENTS CONTINUED □ Option B: Eligibility for Medicaid or Cash Assistance MEDICAID (“Medically Needy” does NOT meet TANF CASH ASSISTANCE eligibility) □ Letter of Eligibility for Medicaid for HIPPY child □ Letter of Eligibility for Cash Assistance (*Letter must include first page that contains Department of (*Letter must include first page that contains Department of Children and Families letterhead and date.) Children and Families letterhead and date.) □ Screen Print from DCF database with child’s information □ Screen Print from DCF database with child’s information RELEASE STATEMENT: I authorize my local HIPPY agency to retrieve my family’s information from the DCF database from July 1, 2014 to June 30, 2015. □ Yes □No - if Yes, please initial:

***ALL SIGNATURES ARE REQUIRED FOR COMPLETION OF APPLICATION***

(Additionally, if “Option A: Income Eligibility” was used to qualify for TANF eligibility, then parent must initial the bottom of page 2 of the TANF form to be complete.)

Parent’s Signature: Date:

Home Visitor/Recruiter’s Signature: Date:

Coordinator’s Signature of Approval: Date:

FOR FLORIDA HIPPY T&TA CENTER USE ONLY NOTES: Pay stubs: □ Weekly □ Bi-weekly □ Semi-monthly □ Monthly

$ $ $ $ $ $ = $

Approval Verified by FL HIPPY T&TA Center: Date:

FLORIDA HIPPY T&TA CENTER University of South Florida - FMHI-MHC-2113A - 13301 Bruce B. Downs Blvd. - Tampa, FL 33612 Tel.: (813)-974-2177 - Fax: (813)-974-6115 - http://floridahippy.fmhi.usf.edu