Child Income
	Weekly
	Every 2 Weeks
	2X Month
	Monthly
	Annual
	
$Click or tap here to enter text.

Application #:
2024-2025 School Meals and Summer EBT Application (For Both Standard & CEP Schools/Sites) Complete one application per household. Please use a pen (not a pencil).

APPLY ONLINE: Click or tap here to enter text. RETURN TO (School/District Name): ADDRESS: Click or tap here to enter text.

STEP 1
	List ALL children, infants, and students up to and including grade 12. Attach another sheet of paper if you need space for more names.

List ALL children in the household. Do not forget to list infants, children attending other schools, children not in school, and children not applying for benefits. This includes children not related to you in your household.

Child’s First Name	MI	Child’s Last Name	School	Grade	Foster Child     Migrant Worker     Runaway     Homeless ☐	☐	☐	☐
☐	☐	☐	☐

If you checked any of these boxes, please refer to the
Application

☐	☐	☐	☐

☐	☐	☐	☐

Instruction’s Step 1: Part C
& Part D.

STEP 2
	Do any household members (including you) participate in: SNAP, TANF, or FDPIR?

NO ➔ Go to STEP 3.	YES ➔ Write case number here and proceed to STEP 4.	CASE NUMBER (NOT EBT NUMBER): Click or tap here to enter text.	Write only one case number in this space.

STEP 3
	List ALL household members and income for each member (before taxes and deductions)

A. All Adult Household Members (Anyone who is living with you and shares income and expenses, even if not related, including you.)
List all Adult Household Members not listed in STEP 1 (including yourself ) even if they do not receive income. For each Household Member listed, if they receive income, report total gross income (before taxes and deductions) 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.

Public How often received?	Assistance,

Pensions, Retirement,
How often received?	Social Security, SSI,	How often received?

Earnings Name of Adult Household Members (First and Last)	from Work
	
Weekly
	Every 2 Weeks
	
2x Month
	
Monthly
	
Annual
	Child Support, Alimony
	
Weekly
	Every 2 Weeks
	
2x Month
	
Monthly
	VA Benefits, All Other Income
	
Weekly
	Every 2 Weeks
	
2x Month
	
Monthly
	
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Total Household Members (Children and Adults)	*Last Four Digits of Social Security Number (SSN) of Primary Wage	Check if no SSN	Check to Opt-out of Summer EBT Benefits EarnerorotherAdult Household Member (If Applicable)

B. Child Income
Sometimes children in the household earn or receive income. Include the TOTAL income (before taxes and deductions) received by ALL children listed in STEP 1 here.

How often received?

Please see application’s back for list of income sources.

STEP 4
	Contact information and adult signature.
		RETURN COMPLETED FORM TO YOUR CHILD’S SCHOOL:
	Insert school address here

“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 (confirm) the information. I am aware that if I purposely give false information, my children may lose meal and/or Summer EBT benefits, and I may be prosecuted under applicable State and Federal laws.
For Summer EBT Only: I certify that I am not already receiving Summer EBT benefits in another State.

Click or tap here to enter text. Print Name of Adult Signing the Form	Signature of Adult	Today’s Date

Mailing Address (REQUIRED)	City	State	Zip	Phone	Email

SOURCES AND EXAMPLES OF INCOME
	For additional information on income, please refer to the instructions that accompany this application.

Sources of Income
	
Earnings from Work
	Public Assistance/Alimony/ Child Support
	Pensions/Retirement/
All other sources of income
	
• Salary, wages, cash bonuses, tips, commissions • Net income from self-employment (farm or
business)
If you are in the U.S. Military:
• Basic pay and cash bonuses (do NOT include combat pay, FSSA, or privatized housing allowances)
• Allowances for off-base housing, food, and clothing
	• Unemployment benefits • Workers’ compensation
• Supplemental Security Income (SSI) • Cash assistance from State or local
government
• Alimony payments
• Child support payments • Veterans’ benefits
• Strike benefits
	• Social Security/Disability (including railroad retirement and black lung benefits)
• Private Pensions or disability benefits • Income from trusts or estates
• Annuities
• Investment income • Earned interest
• Rental income
• Regular cash payments from outside household

Examples of Income for Children

• A child has a regular full or part-time job where they earn a salary or wages
	
• A child is blind or disabled and receives Social Security benefits
• A parent is disabled, retired, or deceased, and their child receives Social Security benefits
	
• A friend or extended family member regularly gives a child spending money
	
• A child receives regular income from a private pension fund, annuity, or trust

OPTIONAL
	Children’s ethnic and racial identities. This information is kept confidential and may be protected by the Privacy Act of 1974.

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): ☐ Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin, regardless of race)	☐ Not Hispanic or Latino

Race (check one or more): ☐American Indian or Alaska Native	☐ Asian	☐ Black or African American	☐ Native Hawaiian or Other Pacific Islander	☐ White

Return this completed form to your child’s school. *Do not mail, fax, or email completed applications to the U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights.

DO NOT FILL OUT
	For School Use Only.

Annual Income Conversion: Weekly × 52, Every 2 Weeks × 26, Twice a Month × 24, Monthly × 12. Do not annualize income to determine eligibility unless more than one income frequency is listed.

Total Income
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How Often?	Household Size	Federal Income Eligibility	If Federal Denied: Eligible for NJEIE? Click or tap here to enter text.

Weekly
	Every 2 Weeks
	2x Month
	Monthly
	Annual

Free
	Reduced
	Denied

Categorical Eligibility ☐

Click or tap here to enter text. Determining Official’s Signature

Click or tap to enter a date. Date

Click or tap here to enter text. Confirming Official’s Signature

Click or tap to enter a date. Date

Click or tap here to enter text. Verifying Official’s Signature

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Use of Information Statement ________________________________________________________________________________________________________________________________________________________________

The Richard B. Russell National School Lunch Act requires that we use information from this application to see who qualifies for free or reduced price meals. We can only approve complete forms. We may share your eligibility information with education, health, and nutrition programs to help them deliver program benefits to your household. Inspectors and law enforcement may also use your information to make sure that program rules are met.
Please be sure to provide the last four numbers of the Social Security number of the adult household member who signs the application. If the adult does not have one, ‘Check if no Social Security Number’. Applications for a foster child do not need to list a Social Security number. Applications for children in households receiving Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) or Food Distribution Program on Indian Reservations (FDPIR) do not need to list a Social Security number.
Some children qualify for free meals without an application. Please contact your school to get free meals for a foster child, and children who are homeless, migrant, or runaway.

Return completed form to your child’s school.

The contact information below is solely to file a complaint of discrimination.

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form
which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

* MAIL:      U.S. Department of Agriculture	FAX:	(833) 256-1665 or (202) 690-7442; or	* Do not mail applications to Office of the Assistant Secretary for Civil Rights	EMAIL:	Program.Intake@usda.gov                                  this address, only complaints 1400 Independence Avenue, SW                                                                                                                                     of discrimination. Washington, D.C. 20250-9410
This institution is an equal opportunity provider.