Check all that apply

EarningsfromWork
	Weekly
	Bi-Weekly
	2xMonth
	Monthly

					

					

Child Support/Alimony
	Weekly Bi-Weekly
	2xMonth
	Monthly

					

					

Application #:
2022-2023 Application for Free and Reduced Price School Meals Complete one application per household. Please type or use a pen (not a pencil).

Available online at:

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)

Definition of Household	Child’s First Name	MI	Child’s Last Name	[press spacebar to advance]	School Name (Abbr.) Grade 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.

Student attends this school district?
Yes     No

Migrant Worker, Foster     Homeless, Child       Runaway

STEP 2
	Do anyHousehold Members (including you) currentlyparticipate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?	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.

	ReportIncomeforALLHouseholdMembers (Skipthisstepifyouanswered‘Yes’toSTEP2)

Child income
		Weekly
	Bi-Weekly
	2xMonth
	Monthly

How often? 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.	$

B. All Adult Household Members (including yourself)

Are you unsure what income to include here?

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.

Flip the page and 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.

Name of Adult Household Members (First and Last)

$

$

$

$

$

How often?	Public Assistance/	How often?

$

$

$

$

$

Pensions/Retirement/ All Other Income

$

$

$

$

$

How often?

Weekly     Bi-Weekly 2xMonth     Monthly

Total Household Members (Children and Adults)

LastFourDigitsofSocialSecurityNumber(SSN)of

PrimaryWageEarnerorOtherAdultHouseholdMember

X
	X
	X

Check if no SSN

STEP 4
	Contact information and adult signature.
	Mail Completed Form To:

X
	X

“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.”

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

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

PublicAssistance/
AllOtherIncome

INSTRUCTIONS
	Sources of Income

Do not ﬁll out
	For School Use Only

Sources of Income for Children
	
SourcesofChildIncome
	Example(s)
	
- Earnings from work
	- A child has a regular full or part-time job where they earn a salary or wages
	
- Social Security
- Disability Payments - Survivor’s Beneﬁts
	-A childis blindordisabledandreceivesSocial Securitybeneﬁts
-A Parentis disabled,retired,ordeceased,and theirchildreceivesSocialSecuritybeneﬁts
	
-Income from person outside the household
	- A friend or extended family member regularly gives a child spending money
	
-Income from any other source
	- A child receives regular income from a private pension fund, annuity, or trust

Sources of Income for Adults
	
EarningsfromWork
	
Alimony/ChildSupport
	Pensions/Retirement/
	
- Salary, wages, cash bonuses
- Net income from self-employment (farm or business)

If you are in the U.S. Military:

- Basicpayandcashbonuses (doNOTincludecombatpay, FSSAorprivatizedhousing allowances)
- Allowancesforoff-base housing,foodandclothing
	- Unemployment beneﬁts - Worker’s compensation - Supplemental Security Income (SSI)
- Cash assistance from State or local government
- Alimony payments
- Child support payments - Veteran’s beneﬁts
- Strike beneﬁts
	- Social Security (including railroad retirement and black lung beneﬁts)
- Private pensions or disability benefits
- Regular income from trusts or estates
- Annuities
- Investment income - Earned interest
- Rental income
- Regular cash payments from outside household

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(checkone):	Hispanic or Latino	Not Hispanic or Latino

Race(checkoneormore): American Indian or Alaskan Native	Asian	Black or African American	Native Hawaiian or Other Paciﬁc Islander	White

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 thelast fourdigitsof thesocial securitynumber of the adulthouseholdmember 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.

Inaccordance with Federal civil rightslaw andU.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 discriminating 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 availablein languages other than English.

To ﬁle a program complaintof discrimination, complete the USDA Program DiscriminationComplaint Form, (AD-3027)foundonlineat:http://www.ascr.usda.gov/complaint_ﬁling_cust.html,andatanyUSDA office,or writea letter addressed to USDA andprovide in theletter all of the information requested in the form.To request a copy of thecomplaintform, call (866) 632-9992. Submit your completed form or letter to USDA by:

mail civil rightscomplaintsonly to: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW Washington, D.C. 20250-9410

fax:	(202) 690-7442; or

email:	program.intake@usda.gov.

This institution is an equal opportunity provider.

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly x 12 How often?

Total Income		Household Size

Categorical Eligibility

Eligibility:

Weekly
	Bi-Weekly
	2xMonth
	Monthly
	 Annual

Free
	Reduced
		Denied

Determining Official’s Signature	Date	Conﬁrming Official’s Signature	Date	Verifying Official’s Signature	Date