Prototype Application for Free and Reduced Price School Meals



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2015-2016 Prototype Application for Free and Reduced Price School Meals

Complete one application per household. Please use a pen (not a pencil).



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)

MI

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

If you answered NO > Complete STEP 3.

If you answered YES > Write a case number here then go to STEP 4 (Do not complete STEP 3)

Case Number:

Write only one case number in this space.

STEP 3

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

How often?

A. Child Income

Sometimes children in the household earn income. Please include the TOTAL income earned by all Household Members listed in STEP 1 here.



Child income

$

How often?

How often?

How often?

Name of Adult Household Members (First and Last)

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Total Household Members (Children and Adults)

Check if no SSN

“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.”

Apt #

Daytime Phone and Email (optional)


















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Return to: Grayson County School Food Service

790 Shaw Station Rd./P.O. Box 4009, Leitchfield, KY42755








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.






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Click all that apply

Weekly Bi-Weekly 2x Month Monthly

Weekly Bi-Weekly 2x Month Monthly

Weekly Bi-Weekly 2x Month Monthly

Earnings from Work Weekly Bi-Weekly 2x Month Monthly



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.


Last Four Digits of Social Security Number (SSN) of Primary Wage Earner or Other Adult Household Member

Pensions/Retirement/
All Other Income

X X X

X X

Today’s date

Signature of adult completing the form

Contact information and adult signature

Printed name of adult completing the form

Street Address (if available)

STEP 4

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 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.



Zip

State

City

Public Assistance/
Child Support/Alimony

Child’s First Name

Homeless, Migrant, Runaway

Foster Child

Student?

Yes No


Child’s Last Name

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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.

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


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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 filing 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.















OPTIONAL

Children's Racial and Ethnic Identities

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):

Hispanic or Latino

Not Hispanic or Latino



American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander White





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