Head Start Eligibility Verification Form

The Head Start Eligibility Verification Form complies with the eligibility final rule, Head Start Program Performance Standard 45 CFR 1305, released on Feb. 10, 2015. This form was first made available through ACF-PI-HS-10-02, which is currently under review. Programs may continue to use the form to determine eligibility in accordance with the final rule. Note: This resource is under review.

Head Start Eligibility Verification Form cover

Head Start Eligibility Verification Form [PDF, 158KB]

The Office of Head Start (OHS) has created an optional eligibility verification form as a useful tool to assist programs determine eligibility. This version reflects a new Office of Management and Budget (OMB) number and expiration date. Other than the new OMB number and the expiration date, the form has not changed from the one made available in 2010. Select this link to download the eligibility verification form [PDF, 158KB].

Head Start Eligibility Verification Form. HHS/ACF/OHS. 2016. English.

Last Reviewed: October 2016

Last Updated: October 27, 2016