SNAP-Ed Site Eligibility Verification Form
Federal Fiscal Year 2016
The California Department of Aging (CDA) Supplemental Nutrition Assistance Program-Education
(SNAP-Ed) grant is a federally funded program from the US Department of Agriculture, Food and Nutrition Service. SNAP-Ed target audiences are CalFresh recipients and eligible CalFresh populations age 60 and older. CDA SNAP-Ed site(s) must meet one of the following CDA SNAP-Ed site eligibility methodologies:
Method 1. Income Targeting Data - The congregate site address is within an eligible low-income census tract. (Greater than 50 percent of residents have incomes below 185 percent of the Federal Poverty Guideline (FPG)) 2. For more information on census tract data, refer to Methodology 3 in the USDA/WRO Targeting Methodologies Summary Document.
Method 2. Means-Tested Setting - The setting is qualified based on the population it serves and not its physical location (e.g., public housing, Commodity Food Distribution sites, etc.). For more information on means-tested settings, refer to Methodology 1 in the USDA/WRO Targeting Methodologies Summary Document.
Method 3. Intake Records - Fifty percent of congregate site participants have incomes below 100 percent of the FPG1, as determined by income levels from the Title IIIC intake forms found on the CDA Title III Intake Forms Guide.
Method 4. Survey - Fifty percent of congregate site participants must have incomes below 185 percent of the FPG2. Participant income is determined by individual participant queries conducted at the congregate meal site. (Queries may be completed on the day of largest attendance).
For CDA Methods 3 and 4, fill in the required information below, then sign and date. Complete one form per eligible site. SNAP-Ed site eligibility must be evaluated annually and the documentation must be kept on file at the contracting agency. ______
Contact Information:
Agency Name: ______
Congregate Meal Site Name: ______
Physical Address: ______
City: ______Zip: ______Phone: ______
Documentation:
Total number (#) of % or # of participants % or # of participants
participants served below 100% of FPG below 185% of FPG ______
Sources of Documentation: Provide your source and type of documentation/methodology. ______
______
Signature:
Agency or Site Representative Title Date
Print Name
Federal Poverty Levels (2016): 100% FPG $11,8801 and 185% FPG $21,9782
SOURCE: Federal Register, Vol.81, No.15, January 25, 2016, 4036-4037
California Department of Aging v. 3-24-16