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Online Application for School Meal Benefits
HOW TO APPLY
LEARN MORE ABOUT THE PROGRAM
2019-2020 Application for Free and Reduced Price School Meals
Please enable JavaScript in your browser to complete this form.
STEP 1 | List ALL household members who are infants, children, and students up to and including grade 12.
Definition of Household Member:
“Anyone who is living with you and shares income and expenses, even if not related.” Children in Foster care and children who meet the definition of Homeless, Migrant or Runaway are eligible for free meals. Read How to Apply for Free and Reduced Price School Meals for more information.
Child 1 Name
*
First
Middle
Last
School Name
*
Grade
*
Does Child 1 attend this school district?
*
Yes
No
Check all that apply to Child 1
Foster Child
Migrant Worker
Homeless
Runaway
Child 2 Name
First
Middle
Last
School Name
Grade
Does Child 2 attend this school district?
Yes
No
Check all that apply to Child 2
Foster Child
Migrant Worker
Homeless
Runaway
Child 3 Name
First
Middle
Last
School Name
Grade
Does Child 3 attend this school district?
Yes
No
Check all that apply to Child 3
Foster Child
Migrant Worker
Homeless
Runaway
Child 4 Name
First
Middle
Last
School Name
Grade
Does Child 4 attend this school district?
Yes
No
Check all that apply to Child 4
Foster Child
Migrant Worker
Homeless
Runaway
Child 5 Name
First
Middle
Last
School Name
Grade
Does Child 5 attend this school district?
Yes
No
Check all that apply to Child 5
Foster Child
Migrant Worker
Homeless
Runaway
STEP 2 | Do any household members (including you) currently participate in one or more of the following assistance programs? SNAP. TANF, FDPIR
Checkboxes
*
Yes
No
If you answered NO, complete Step 3. If you answered YES, enter a case number here then go to Step 4 (do not complete Step3)
Case # (Write only one case # in this space)
STEP 3 | Report income for ALL Household Members (Skip this step if you answered YES to Step 2)
Are you unsure what income to include here? Review the charts titled "Sources of Income" for more information. The "Sources of Income for Children" chart will help you with the Child Income section. The "Sources of Income for Adults" chart will help you with the ALL Adult Household Members section.
A. Child Income.
Sometimes children in the household earn or receive income. Please include the TOTAL income received by all Household Members listed in STEP 1 here.
Child Income ($)
How Often?
Weekly
Bi-weekly
2x month
Monthly
B. All Adult Household Members (including yourself)
List all Household Members not listed in STEP 1 (including yourself) even if they do NOT receive income. For each Household Member listed, if they DO receive income, report total gross income (before taxes) for each source in whole dollars (no cents) only. If they do NOT receive income from any source, write "0". If you enter "0" or leave any fields blank, you are certifying (promising) that there is no income to report.
Name of 1st Adult Household Members (First and Last)
*
Earnings from Work
*
How Often?
*
Weekly
Bi-weekly
2x month
Monthly
Earnings from Assistance, Child Support, Alimony
How Often?
Weekly
Bi-weekly
2x month
Monthly
Earnings from Pension, Retirement, Other Income
How Often?
Weekly
Bi-weekly
2x month
Monthly
Name of 2nd Adult Household Members (First and Last)
Earnings from Work
How Often?
Weekly
Bi-weekly
2x month
Monthly
Earnings from Assistance, Child Support, Alimony
How Often?
Weekly
Bi-weekly
2x month
Monthly
Earnings from Pension, Retirement, Other Income
How Often?
Weekly
Bi-weekly
2x month
Monthly
Name of 3rd Adult Household Members (First and Last)
Earnings from Work
How Often?
Weekly
Bi-weekly
2x month
Monthly
Earnings from Assistance, Child Support, Alimony
How Often?
Weekly
Bi-weekly
2x month
Monthly
Earnings from Pension, Retirement, Other Income
How Often?
Weekly
Bi-weekly
2x month
Monthly
Name of 4th Adult Household Members (First and Last)
Earnings from Work
How Often?
Weekly
Bi-weekly
2x month
Monthly
Earnings from Assistance, Child Support, Alimony
How Often?
Weekly
Bi-weekly
2x month
Monthly
Earnings from Pension, Retirement, Other Income
How Often?
Weekly
Bi-weekly
2x month
Monthly
Name of 5th Adult Household Members (First and Last)
Earnings from Work
How Often?
Weekly
Bi-weekly
2x month
Monthly
Earnings from Assistance, Child Support, Alimony
How Often?
Weekly
Bi-weekly
2x month
Monthly
Earnings from Pension, Retirement, Other Income
How Often?
Weekly
Bi-weekly
2x month
Monthly
Total Household Members (Children and Adults
*
Last 4 digits of Social Security Number of Primary Wage Earning or Other Adult Household Member
*
Check if you have NO Social Security Number
NO SS#
STEP 4 | Contact information and Adult Signature
"I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with Federal funds and that school officials may verify (check) this information. I understand that if I purposely given false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws."
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone (Optional)
Email (Optional)
Name
*
First
Last
Today's Date
*
OPTIONAL | Children's Racial and Ethnic Identities
We are required to ask for information about your child's race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your child's eligibility for free or reduced price meals.
Ethnicity (Check 1)
Hispanic or Latino
Not Hispanic or Latino
Race (Check 1 or more)
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Optional Information Explanation
The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservation (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate fund, or determine benefits for their programs, auditors for program reviews; and law enforcement officials to help them look into violations of program rules.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies the USDA, its Agencies, offices, and employees, and Institutions participating in or administering USDA programs are prohibited from discrimination based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.) should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
Mail Civil Rights Complaints only to:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Ave., SW
Washington, D.C. 20250-9410
Fax: 202-690-7442
eMail: program.intake@usda.gov
This institution is an equal opportunity provider.
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