MODIFIED FY 2009-10 APPLICATION FOR FREE AND REDUCED-PRICE SCHOOL MEALS
You must fill out a new application each school year
ONE APPLICATION PER HOUSEHOLD Dear Parent/Guardian: Your School District participates in the National School Lunch Program/School Breakfast Program. If your gross income is the same or less than the amount listed in the chart below, complete this application and return it to your child’s school. We cannot approve an application that is not complete. WIC participants may be eligible for free or reduced price meals. Please call the following number ________452-7428________ if you need help:
INSTRUCTIONS: In addition to completing the adult signature, date, INCOME CHART address and phone number, please complete the section below that Effective July 1, 2009 to June 30, 2010 applies to your household. Household Annual Monthly Weekly Size 1. STUDENTS WHO ARE FOSTER CHILDREN 1 20,036 1,670 386 ; Child’s name (each Foster Child needs a separate application) 2 26,955 2,247 519 ; Child’s personal income 3 33,874 2,823 652 2. STUDENTS WITH FOOD STAMP/TEMPORARY ASSISTANCE TO 4 40,793 3,400 785 FAMILIES IN IDAHO OR FDPIR CASE NUMBERS 5 47,712 3,976 918 ; Name/Names of children who receive benefits 6 54,631 4,553 1,051 ; CASE number for each child (EBT or quest card # not allowed) 7 61,550 5,130 1,184 3. ALL OTHER STUDENTS 8 68,469 5,706 1,317 ; All household members For each ; Gross income by person including how often income is additional +6,919 +577 +134 received (weekly, monthly, etc.) member add ; Social Security Number of adult signer
I certify that all of the information provided is true and correct and that all income is reported. I understand that this information is being given for the receipt of federal funds; that school officials may verify the information on the application; and that deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws. ； CHECK HERE: If children listed on the application are new to this school or did not receive free and reduced meals last year. __ _______ ____________________ Signature of Adult Household Member or Foster Parent Printed Name of Adult Household Member or Foster Parent Date Signed Street/Apt. Number P. O. Box No. ____________ City State Zip Code Home Phone No. Work Phone No. GRADE SCHOOL CHILD’S PERSONAL INCOME 1. FOSTER CHILD GRADE NAME OF SCHOOL List the FOOD STAMP, TAFI, or FDPIR 2. STUDENTS WITH FOOD STAMP, TEMPORARY ASSISTANCE case number for each child TO FAMILIES IN IDAHO OR FDPIR CASE NUMBERS 1 2 3 4 Earnings from Work Welfare, Child Pensions, ALL OTHER 3. List the names of everyone in your Before Deductions Support, Alimony Retirement, Social INCOME household and gross income they receive Received Security except children listed above (unless income Students earned.) If household member listed below has Only no income, you must check the NO INCOME Students Only box. How often income is received must be How How How How How How How How answered. Much? Often? Much? Often? Much? Often? Much? Often? NAME NO GRADE NAME OF SCHOOL INCOME 1 ; 2 ; 3 ; 4 ; 5 ; 6 ;
; Total number of household members – Attach a sheet of paper listing other household members if needed. SOCIAL SECURITY NUMBER OF ADULT HOUSEHOLD MEMBER WHO IS SIGNING THIS APPLICATION
_ _ _ - _ _ - _ _ _ _ ; I do not have a Social Security Number
RACE/ETHNIC IDENTITY-OPTIONAL Mark one or more racial identities:
; BLACK OR AFRICAN AMERICAN
; AMERICAN INDIAN OR ALASKA NATIVE
; NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
; OTHER Mark one ethnic identity:
; HISPANIC OR LATINO
; NON HISPANIC OR LATINO
PLEASE NOTE: Verification: Your eligibility may be checked at any time during the school year. School officials may ask you to send papers showing that your children should receive free or reduced price meals.
Fair Hearing: You may talk to school officials if you do not agree with the school’s decision on your application or the results of verification. You also may ask for a fair hearing. You may do this by calling or writing:
P. O. Box A
Fruitland, Idaho 83619
Reapplication: You may apply for meals anytime during the school year. If you are not eligible now but have a change, like a decrease in household income, an increase in household size, become unemployed or receive food stamps or TAFI for your children, complete an application then. Confidentiality: This application could be used for Federal and State initiated education programs along with USDA child nutrition meals.
PRIVACY ACT STATEMENT: This explains how we will use the information you give us. 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 social security number of the adult household member who signs the application. The social security number is not required when you apply on behalf of a foster child or you list a Food Stamp Program, Temporary Assistance for Families in Idaho (TAFI) 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 review, and law enforcement officials to help them look into violations of program rules. To find out more about programs in your community, contact the 2-1-1 Idaho CareLine by dialing 211 or 1-800-926-2588. Se habla espanol. “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.” USDA is an equal opportunity provider and employer.
DO NOT WRITE IN BOX BELOW - FOR SCHOOL USE ONLY
ANNUAL INCOME CONVERSION: Weekly X 52, Every 2 Weeks X 26, Twice a Month X 24, Monthly X 12 DENIED: ;Income Over Allowed Amount ; FOOD STAMP/TAFI/FDPIR HOUSEHOLD ;Incomplete/Missing ; INCOME HOUSEHOLD: Total household income: $_______________ How often ______________ Household size:________ ;Other TEMPORARY APPROVAL FOR: VERIFICATION RESULTS: APPLICATION APPROVED FOR: ;Free Meals, expires ____________________ ; No Change ; Free to Reduced ; Reduced to Free ; Free Meals ;Reduced-Price Meals, expires ____________ ; Reduced-Price Meals Reduced-Price Meals ; Ineligible (Reason) ; _____________ WITHDRAWAL DATE Signature of confirming Official _______________________________ Signature of Signature of Date Determining Official: X Verifying Official: X ndDate Date Date 2 Date 1st Signed: Notice Sent: Notification Sent: Notification Sent: