|
2009-2010 HOUSEHOLD APPLICATION FOR FREE AND REDUCED
PRICE MEALS
COMPLETE ONE APPLICATION PER HOUSEHOLD |
Office Use Only
|
Complete
sign, and return the application to any school in the
division. Please read the instructions on the back of this
form. Call the school nutrition office if you need help
completing this form.
Part 1.
Children in School. (Use a separate application for
each foster child.)
|
|
LAST NAME |
FIRST NAME |
M.I. |
GRADE |
SCHOOL |
STUDENT ID #
(if applicable) |
LIST SNAP or TANF
CASE NUMBER (if
applicable) |
|
1 |
|
|
|
|
|
|
|
|
2 |
|
|
|
|
|
|
|
|
3 |
|
|
|
|
|
|
|
|
4 |
|
|
|
|
|
|
|
|
5 |
|
|
|
|
|
|
|
|
6 |
|
|
|
|
|
|
|
|
If you are getting
SNAP (formerly the Food Stamp Program) or TANF for
your child(ren), list the case number(s) above. DO
NOT complete Parts 2, 3, or 4. Go to Part 5. |
Part
2. If the child
you are applying for is homeless, migrant, or a runaway,
check the appropriate box and call your school to talk to
the homeless liaison or migrant coordinator. Complete Parts
1, 4, 5, 6, 7.
£
Homeless
£
Migrant
£
Runaway
Part
3. If this is a
FOSTER CHILD, who is the legal responsibility of the
courts, check here
£
and write the
child’s monthly “personal use” income here: $
_____________. Write “0” if the child has no
personal use income. DO NOT complete Part 4. Go
to Part 5.
Part
4. ALL OTHER HOUSEHOLDS:
(Complete this part
only if you did not complete Part 3 or if you did not list a
SNAP or TANF case number in Part 1.) List gross
income before any deductions and tell us how often it
was received.
|
Names of all
Household Members
List all household
members, including the
child(ren) listed
above.
Do Not Complete if
this is a Foster Child, or if you listed a SNAP or
TANF case number in Part 1. |
Age |
List Gross Income
(before any deductions) in whole dollars. Write in
how often income is received, for example:
(W) = Weekly
(E) or (2W) = Every 2 Weeks (T) or (2M) =
Twice a Month (M) = Monthly (Y) =
Yearly |
|
Earnings from Work
Before Deductions, Wages, Salaries, and
Tips, or Strike Benefits, Unemployment Benefits,
Worker’s Compensation or Earnings from Self-owned
Business. |
Welfare, Child
Support, Alimony
$ Amount / How Often |
Pensions. Retirement,
Social Security
$ Amount / How
Often |
All Other Income
(See Back of Form)
$ Amount / How
Often |
Check if
No Income |
|
Job 1
$ Amount / How
Often |
Job 2
$ Amount / How
Often |
|
1 |
|
/ |
/ |
/ |
/ |
/ |
£ |
|
2 |
|
/ |
/ |
/ |
/ |
/ |
£ |
|
3 |
|
/ |
/ |
/ |
/ |
/ |
£ |
|
4 |
|
/ |
/ |
/ |
/ |
/ |
£ |
|
5 |
|
/ |
/ |
/ |
/ |
/ |
£ |
|
6 |
|
/ |
/ |
/ |
/ |
/ |
£ |
|
7 |
|
/ |
/ |
/ |
/ |
/ |
£ |
|
8 |
|
/ |
/ |
/ |
/ |
/ |
£ |
Part
5. RACIAL IDENTITIES:
You are not required to answer
this question. If you choose to do so: Please mark one or
more of the following racial identities:
£
American Indian / Alaska Native
£
Asian
£
Black or African American
£
Native Hawaiian or Other Pacific Islander
£
White
£
Other
ETHNIC
IDENTITIES: Please mark one of the following
ethnic identities:
£ Hispanic or
Latino
£ Not Hispanic or
Latino
Part
6. OTHER BENEFITS: Medicaid & Health Insurance: Your child may be eligible for other benefits. The school is allowed
to share the information on this application with Medicaid
and the Virginia children’s health
insurance program called FAMIS. If you do not
want this information shared you must tell us by checking
the NO block below. Your decision will not affect your
child’s eligibility for free or reduced price meals.
£
No,
I do not want school officials to share information from my
free or reduced price meal application with Medicaid or
FAMIS.
Part
6b. Others:
Your permission is required for the school to use this
information for other benefits. YES, I give
permission for the information provided on this application
to be used only for the program(s)
checked. I understand that I give up rights to
confidentiality for this specific purpose only.
£
_FREE
BUS_________________
£
__________________
£
__________________
£
__________________
£
__________________
Part
7. SIGNATURE & SOCIAL SECURITY NUMBER:
An adult must sign the
application and provide a social security number before it
can be approved. (See Privacy Act Statement on back.)
PENALTIES
FOR MISREPRESENTATION:
I certify that all of the
above information is true and correct and that the SNAP or
TANF number is correct or that all income is reported. I
understand that this is information being given for the
receipt of Federal funds; that institutional
officials may verify the
information on the statement and that the deliberate
misrepresentation of the information may subject me to
prosecution under applicable State and Federal laws.
|
£££-££-££££
Social Security #
of Adult Signing Application
|
£ I Do Not Have A Social Security Number |
S
I G N H E R E
Signature of Adult
Household Member |
|
|
Date |
|
Mailing Address:
___________________________________________________________________________
Home Phone: _______________________ Work Phone:
_____________________
|
DO NOT WRITE
BELOW THIS LINE – SCHOOL USE ONLY – Yearly
Income Conversion for Approving Official When
Different Income Frequencies are Reported:
Weekly X 52 Every 2 Weeks X 26 Twice
a Month X 24 Monthly X 12
|
|
Total Income / How
Often:
$
_____________________ / _______________
Household Size:
____________
|
Approved:
£ Free
£ Temp. Free,
£ Reduced Expires: ____ |
£ Denied
|
Reason:
£ Income too
High
£ Incomplete
Application |
£ SNAP
£ TANF
£ Foster Child
|
Date Approval / Denial Notice Sent to Household:
____________
Signature of Approving Official:
__________________________ |
|
STUDENT TRANSFER
INFORMATION: Transferred / Withdrawn
Date:
Transferred To: |
|
VERIFICATION SUMMARY:
Date Selected: ___________
Date Confirmed: _________
Confirmers Initials:________ |
Date Response Due:___________
Date of 2nd Notice:_____________
Date Results Notice Sent::_______ |
Verification Results:
£ No Change
£ Free to Reduced
£ Reduced to
Free
£ Free to Paid £
Reduced to Paid |
Reason for Change:
£ Income
£ Household
Size
£ Refused to Cooperate
£ Change in SNAP / TANF |
Date Completed: ____________
Verifying Official’s Signature:
____________________
|
| |
|
|
|
|
|
|
|
|
|
|
|
INSTRUCTIONS FOR COMPLETING
THE HOUSEHOLD APPLICATION FOR FREE AND REDUCED PRICE MEALS
To apply
for free or reduced price meals, complete one
application for ALL children in the household who
are in school using the following instructions.
Sign the application
and return the application to any school in the school
division or the school nutrition office. Call the school
nutrition office if you need help.
|
PART 1 - STUDENT INFORMATION: ALL HOUSEHOLDS
COMPLETE PART 1.
1. Print the names of all children in the
household who are in school.
2. List the grade, the school and the student’s
school ID# for each child.
3. List a current
Supplemental Nutrition Assistance Program (SNAP)
benefits (formerly the Food Stamp Program)
or TANF case number for each child. This number is
in your approval letter.
If you list a SNAP or TANF number you do not need to list
names of household
members or income. No social security number is needed if a
SNAP/TANF case number is provided. These households
should SKIP Part 4 and COMPLETE Parts 5, 6, & 7.
4. All
households must sign the application in Part 7.
Income households must provide the social security #
of the adult signing or check the box if they do not
have one. |
|
PART 2 -
Check the appropriate box and contact your school to talk with the
homeless liaison or migrant coordinator.
Fill out the application by
following instructions for ALL OTHER HOUSEHOLDS. |
|
PART 3 - HOUSEHOLDS WITH A FOSTER CHILD COMPLETE
PART 3 AND PARTS 5, 6, & 7.
A foster child is the legal responsibility of a
welfare agency or court.
1. List the foster child's monthly "personal use"
income. Write "0" if the foster child does not get
"personal use" income.
"Personal use" income is (a) money given by the
welfare office identified by category for the
child's personal use, such as for clothing, school
fees, and allowances; and (b) all other money the
child gets, such as money from his/her family and
money from the child's full-time or regular
part-time jobs.
Skip Part 4.
Do not list any other children, household members,
or income.
2. A foster parent
or other official representing the child must sign
the application in Part 7. No social security number
is required. Use a separate application for each
foster child. |
|
PART 4- ALL OTHER HOUSEHOLDS WITHOUT A SNAP
OR TANF NUMBER IN PART 1, including WIC households,
or who did not complete Part 3, MUST COMPLETE PARTS
4, 5, 6 & 7.
1. Write the names
of everyone in your household, whether they get
income or not. Include yourself, all children who
are in school, all other children, your spouse,
grandparents, and other related and unrelated people
in your household. Use another piece of paper if
you need more space.
2. Write the amount of income each household
member got last month, before taxes or
anything else is taken out, and how often it
was received. For example, list the gross income
each person earned from work. The amount should be
listed on your pay stub. This is not the same as
take home pay; it is the amount before taxes and
other deductions. Next to the amount write how
often the person received it. If any amount last
month was more or less than usual, write that
person's usual income.
3. An adult household member must sign the
application in Part 7 and give his/her social
security number or check the box if they don’t have
one. |
TYPES OF INCOME TO REPORT AND HOW TO REPORT THEM ON THE
APPLICATION
|
Names of all Household Members
List all household
members, including the
child(ren) listed
above.
Do Not Complete if
this is a Foster Child,
or if you listed a
SNAP or TANF
case number in Part
1. |
Age |
List Gross Income
(before any deductions) in whole dollars. Write in
how often income is received, for example:
(W) = Weekly
(E) or (2W) = Every 2 Weeks (T) or (2M) =
Twice a Month (M) = Monthly (Y) =
Yearly |
|
Earnings from
Work
Before
Deductions, Wages,
Salaries, Tips,
Strike Benefits,
Unemployment Compensation,
Worker’s Compensation
or
Net Income from
Self-Owned Business or Farm. |
Welfare, Child
Support, Alimony
Payments, Welfare Payments, Alimony/Child Support
Payments
|
Pensions.
Retirement, Social Security
Pensions,
Supplemental Security Income, Retirement Income,
Veteran’s Payments, Social Security
|
All Other Income
Disability Benefits, Cash Withdrawn from Savings,
Interest/ Dividends, Income from Estates/Trusts/
Investments, Regular contributions from persons not
living in the household, Net Royalties/ Annuities/
Net Rental Income, Any Other Income
|
Check if
No Income |
|
Job 1
|
Job 2
|
|
(Example)
Jane Smith
|
42 |
$200 / W (Weekly) |
$100 / E (Every 2
Weeks) |
$150 / M (Monthly) |
$100 / M (Monthl;y) |
$50 / T (Twice per Mo. |
£ |
|
PART 5 - RACIAL/ETHNIC IDENTITY:
Complete the racial/ethnic identity question
if you wish. You are not required to answer this
question to get meal benefits. We need this
information to make sure that everyone is treated
fairly. |
|
PART 6 and 6b – OTHER BENEFITS:
You may be eligible for other benefits. Look at
Part 6 on the application. To obtain meal benefits,
you are not required to complete this section. |
|
PART 7 - SIGNATURE AND SOCIAL SECURITY NUMBER: ALL
HOUSEHOLDS COMPLETE PART 7.
1. SIGN HERE. The application must have the
signature of an adult household member.
2. The application must have the social security
number of the adult who signs. If the adult who
signs does not have a social security number, they
must check the box
FORMCHECKBOX
I Do Not Have A Social Security Number. If you
listed a SNAP or TANF number for each child, or if
you are applying for a foster child, a social
security number is not needed. |
Privacy Act Statement: Unless you list the child’s SNAP or TANF case number, Section 9 of the
National School Lunch Act requires that you include the
social security number of the household member signing the
application or indicate that the household member does not
have a social security number. You do not have to list a
social security number, but if a social security number is
not listed or an indication is not made that the adult
household member signing the application does not have a
social security number, we cannot approve the application.
The social security number may be used to identify the
household member in verifying the correctness of information
stated on the application. This may include program
reviews, audits, and investigations and may include
contacting employers to determine income, contacting a SNAP
or TANF office to determine current certification for SNAP
or TANF benefits, contacting the State employment security
office to determine the amount of benefits received and
checking the documentation produced by the household member
to prove the amount of income received. These efforts may
result in a loss or reduction of benefits, administrative
claims, or legal actions if incorrect information is
reported. The social security number may also be disclosed
to programs as authorized under the National School Lunch
Act and Child Nutrition Act, the Comptroller General of the
U.S., Law enforcement officials for the purpose of
investigating violations of certain federal and state laws,
and local education, health, and nutrition programs.
|
Non-discrimination Statement: In
accordance with Federal law and U.S. Department of
Agriculture policy, this institution is prohibited
from discriminating on the basis of race, color,
national origin, sex, age, or disability. To file a
complaint of discrimination, write USDA, Director,
Office of Civil Rights, 1400 Independence Avenue,
SW, Washington, D.C. 20250-9410 or call (800)
795-3272 or (202) 720-6382 (TTY). USDA is an equal
opportunity provider and employer.
|
Top
USDA INCOME
ELIGIBILITY GUIDELINES
HOUSEHOLD SIZE AND INCOME SCALE
(Effective July 1, 2009
to June 30, 2010)
|
MAXIMUM HOUSEHOLD INCOME FOR FREE MEALS (130%
Federal Poverty Guidelines) |
|
HOUSEHOLD SIZE
|
YEARLY
|
MONTHLY |
TWICE PER MONTH |
EVERY TWO WEEKS
|
WEEKLY |
HOUSEHOLD SIZE
|
|
1 |
$14,079 |
$1,174 |
$ 587 |
$ 542 |
$ 271 |
1 |
|
2 |
$18,941 |
$1,579 |
$ 790 |
$ 729 |
$ 365 |
2 |
|
3 |
$23,803 |
$1,984 |
$ 992 |
$ 916 |
$ 458 |
3 |
|
4 |
$28,665 |
$2,389 |
$1,195 |
$1,103 |
$ 552 |
4 |
|
5 |
$33,527 |
$2,794 |
$1,397 |
$1,290 |
$ 645 |
5 |
|
6 |
$38,389 |
$3,200 |
$1,600 |
$1,477 |
$ 739 |
6 |
|
7 |
$43,251 |
$3,605 |
$1,803 |
$1,664 |
$ 832 |
7 |
|
8 |
$48,113 |
$4,010 |
$2,005 |
$1,851 |
$ 926 |
8 |
|
For Each Additional
Family Member - ADD |
+ $4,862 |
+ $406 |
+ $203 |
+ $187 |
+$94 |
For Each Additional
Family Member - ADD |
|
HOUSEHOLD INCOME RANGE FOR REDUCED PRICE MEALS
(185% Federal Poverty Guidelines) |
|
HOUSEHOLD SIZE |
YEARLY
|
MONTHLY
|
TWICE PER MONTH |
EVERY TWO WEEKS
|
WEEKLY
|
HOUSEHOLD SIZE |
|
1 |
$14,079.01- $20,036 |
$ 1,174.01 - $1,670 |
$ 587.01 - $ 835 |
$ 542.01 - $ 771 |
$ 271.01 - $ 386 |
1 |
|
2 |
$18,941.01 - $26,955 |
$1,579.01 - $2,247 |
$ 790.01 - $1,124 |
$ 729.01 - $ 1,037 |
$ 365.01 - $ 519 |
2 |
|
3 |
$23,803.01 - $33,874 |
$1,984.01 - $2,823 |
$ 992.01 - $1,412 |
$ 916.01 - $1,303 |
$ 458.01 - $ 652 |
3 |
|
4 |
$28,665.01 - $40,793 |
$2,389.01 - $3,400 |
$1,195.01 - $1,700 |
$ 1,103.01 - $1,569 |
$ 552.01 - $ 785 |
4 |
|
5 |
$33,527.01 - $47,712 |
$2,794.01 - $3,976 |
$1,397.01 - $1,988 |
$1,290.01 - $1,836 |
$ 645.01 - $ 918 |
5 |
|
6 |
$38,389.01 - $54,631 |
$3,200.01 - $4,553 |
$1,600.01 - $2,277 |
$1,477.01 - $2,102 |
$ 739.01 - $ 1,051 |
6 |
|
7 |
$43,251.01 - $61,550 |
$3,605.01 - $5,130 |
$1,803.01 - $2,565 |
$1,664.01 - $2,368 |
$ 832.01 - $ 1,184 |
7 |
|
8 |
$48,113.01 - $68,469 |
$4,010.01 - $5,706 |
$2,005.01 - $2,853 |
$1,851.01 - $2,634 |
$ 926.01 - $1,317 |
8 |
|
For Each Additional Family Member - ADD |
+ $6,919 |
+ $ 577 |
+ $289 |
+ $267 |
+ $134 |
For Each Additional Family Member - ADD |
|
CONVERSION FACTORS
-
|
USE ONLY TO CONVERT MULTIPLE FREQUENCY INCOME ON
THE SAME APPLICATION INTO YEARLY INCOME FOR
ELIGIBILITY DETERMINATION:
IF paid WEEKLY: Salary X 52
IF paid EVERY 2 WEEKS: Salary X 26
If paid TWICE PER MONTH: Salary x 24
If paid MONTHLY: Salary
X 12 |
| |
|
|
|
|
|
|
|
Top
Menu Analysis
|
MENU |
Portion |
Calories |
Chol. |
Sod. |
Iron |
Calc. |
Vit A |
Vit C |
Pro. |
Carb |
T Fat |
S Fat |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Ham Biscuit |
1 bis |
160 |
0.61 |
377.1 |
1.77 |
133.9 |
0.73 |
0.02 |
3 |
26.35 |
0 |
1 |
|
|
|
|
|
|
1 sl hm |
40 |
19 |
423 |
0.3 |
3 |
15 |
0 |
6.51 |
0.43 |
0.01 |
0.49 |
|
|
|
|
|
Juice |
1/2 c |
60 |
|
1.2 |
0.2 |
10 |
|
60 |
0.01 |
14.5 |
0 |
0 |
|
|
|
|
|
Milk |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Breakfast Burrito |
1 |
258 |
196 |
564 |
2.95 |
143 |
552 |
5.4 |
12.22 |
31.32 |
|
2.91 |
|
|
|
|
|
Juice |
1/2 c |
60 |
|
1.2 |
0.2 |
10 |
|
60 |
0.01 |
14.5 |
0 |
0 |
|
|
|
|
|
Milk |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Pancakes/Syrup |
2 |
250 |
25 |
595 |
|
|
|
|
|
70 |
|
0.5 |
|
|
|
|
|
Assorted Juices |
1/2 c |
60 |
|
1.2 |
0.2 |
10 |
|
60 |
0.01 |
14.5 |
0 |
0 |
|
|
|
|
|
Milk |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Assorted Cereals |
1 bwl |
106 |
|
148 |
4.2 |
22 |
|
5.3 |
3.28 |
21.77 |
|
0.19 |
|
|
|
|
|
Mini Blueberry Muffin |
1 |
184 |
36 |
184 |
|
|
|
|
3 |
21.6 |
0 |
2 |
|
|
|
|
|
Juice |
1/2 c |
60 |
|
1.2 |
0.2 |
10 |
|
60 |
0.01 |
14.5 |
0 |
0 |
|
|
|
|
|
Milk |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
French Toast Stix/syrup |
3 |
305 |
|
525 |
|
|
|
|
5 |
65 |
|
2 |
|
|
|
|
|
Assorted Cereals |
1 bwl |
106 |
|
148 |
4.2 |
22 |
|
5.3 |
3.28 |
21.77 |
|
0.19 |
|
|
|
|
|
Juice |
1/2 c |
60 |
|
1.2 |
0.2 |
10 |
|
60 |
0.01 |
14.5 |
0 |
0 |
|
|
|
|
|
Milk |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Breakfast Pizza |
1 |
227.25 |
13.61 |
628.1 |
1.75 |
139.7 |
280.95iu |
0.42 |
9.41 |
22.51 |
|
3.37 |
|
|
|
|
|
Juice |
1/2 c |
60 |
|
1.2 |
0.2 |
10 |
|
60 |
0.01 |
14.5 |
0 |
0 |
|
|
|
|
|
Milk |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
MENU |
Portion |
Calories |
Chol. |
Sod. |
Iron |
Calc. |
Vit A |
Vit C |
Pro. |
Carb |
T Fat |
S Fat |
|
|
|
|
|
Assorted Cereal |
1 bwl |
106 |
|
148 |
4.2 |
22 |
|
5.3 |
3.28 |
21.77 |
|
0.19 |
|
|
|
|
|
1/2 English Muffin |
1-Jan |
60 |
0 |
125 |
|
|
|
|
|
