Error prone (Children and Adults)



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Error prone

(Children and Adults)


Total Household Members


Printed name of adult completing the form Signature of adult completing the form Today’s date


STEP 4 Contact information and adult signature


Street Address (if available) Apt # City State Zip Daytime Phone and Email (optional)


“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 the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give


false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.”


Complete one application per household. Please use a pen (not a pencil).
If you have received a NOTICE OF DIRECT CERTIFICATION from the school district for free meals, do not complete this application. But do let the school know if any children in the household are not listed on the Notice of Direct Certification letter you received.



STEP 1 List ALL Household Members who are infants, children, and students up to and including grade 12 (if more spaces are required for additional names, attach another sheet of paper)


Homeless,


Student?


Yes No


Foster Migrant,


Child Runaway


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’s First Name MI Child’s Last Name


$ $ $


$


B. All Adult Household Members (including yourself)


A. Child Income


Agency ID:

*Do not provide EBT card number.


If you answered NO > Complete STEP 3. If you answered YES > Write a agency id here then go to STEP 4 (Do not complete STEP 3)


STEP 2 Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR? Circle one: Yes / No


How often? Public Assistance/ How often? Pensions/Retirement/ How often?


Name of Adult Household Members (First and Last) Earnings from Work Weekly Bi-Weekly 2x Month Monthly Child Support/Alimony Weekly Bi-Weekly 2x Month Monthly All Other Income Weekly Bi-Weekly 2x Month Monthly


How often?


Weekly Bi-Weekly 2x Month Monthly


Sometimes children in the household earn income. Please include the TOTAL income earned by all Household Members


X X X X X Check if no SSN


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 income for each source in


whole dollars 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.


$ $ $


$ $ $


$ $ $


$ $ $


Please read How to


Apply for Free and


Reduced Price School


Meals for more


information. The


Sources of Income for


Children section will


help you with the Child


Income question. The


Sources of Income for


Adults section will help


you with the All Adult


Household Members


section.


listed in STEP 1 here .


Child income


STEP 3 Report Income for ALL Household Members (Skip this step if you answered Yes to STEP 2)


Last Four Digits of Social Security Number (SSN) of


Primary Wage Earner or Other Adult Household Member

mc900411244[1]
2015-2016 Massachusetts Free And Reduced Price School Meals Household Application


Check all that apply





OPTIONAL Children's Racial and Ethnic Identities


Do NOt fill out this part. This is for school use only.




We are required to ask for information about your children’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 children’s eligibility for free or reduced price meals.

Ethnicity (check one):

Race (check one or more):




 American Indian or Alaskan Native

Hispanic or Latino

 Asian

 Not Hispanic or Latino

 Black or African American




 Native Hawaiian or Other Pacific Islander




 White


Only annualize income if there are multiple pay frequencies




Annual Income Conversion:
Weekly x 52
Every 2 Weeks x 26
Twice A Month x 24
Monthly x 12

Categorical Eligibility

Free
Reduced


Denied
Reason: ________________
Total Income: ____________ Household size: __________
Per:
 Week,
 Every 2 Weeks,
 Twice A Month,
 Month,
 Year
Dual Eligibility:
Foster child(ren) – Free _________
Non-foster child(ren) – Free ________ Reduced ________ Denied ___________

Determining Official’s Signature: ___________________________________ Date: ________

Confirming Official’s Signature: ___________________________________ Date: _________

Verifying Official’s Signature: ___________________________________ Date: _________





Use of Information Statement:

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 Reservations (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.



Non-discrimination Statement:

The U.S Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.)

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint__ling_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov

Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).



USDA is an equal opportunity provider and employer

2015-2016 Massachusetts Free And Reduced Price School Meals Household Application


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