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For Adult Care Centers 2022, Rev. 6/21 Child and Adult Care Food ProgramHOUSEHOLD SIZEINCOME STATEMENTComplete this form (HIS) and return it to the center. Complete one HIS per household. Refer to
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To fill out the household size-income statement, follow these steps:
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Begin by providing your personal information such as your name, address, and contact details.
03
Specify the number of individuals living in your household, including yourself and any dependents.
04
Provide the income details of all household members, including salaries, wages, pensions, and any other sources of income.
05
Specify any additional financial information, such as assets or liabilities, that may be necessary for evaluating your household's financial status.
06
Review the completed statement for accuracy and ensure all relevant information has been included.
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Submit the filled-out household size-income statement to the designated authority or organization.

Who needs household size-income statement for?

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The household size-income statement is required by various entities or individuals, including:
02
- Government agencies or social service organizations that provide assistance or benefits based on household income eligibility criteria.
03
- Landlords or housing providers who need to evaluate an applicant's financial capacity to pay rent.
04
- Financial institutions or creditors who may require the statement as part of a loan application or credit assessment process.
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- Local authorities or tax departments that use the information to determine eligibility for tax exemptions or deductions.
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- Immigration authorities who may require the statement as proof of financial stability for visa or residency applications.
07
- Researchers or analysts who collect and analyze data on household income and demographics for statistical purposes.
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The household size-income statement is used to determine the size of the household and the total income earned by all household members.
Any individual or household who receives income must file a household size-income statement.
To fill out the household size-income statement, you will need to provide information on all income earned by household members and specify the size of the household.
The purpose of the household size-income statement is to assess the financial situation of the household and determine eligibility for specific programs or benefits.
The household size-income statement must include all sources of income for household members, as well as the number of people living in the household.
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