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MULTI-USE FREE AND REDUCED-PRICE SCHOOL MEALS APPLICATIONS FOR ...

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MULTI-USE FREE AND REDUCED-PRICE SCHOOL MEALS APPLICATIONS FOR ...

    Instructions for Applying 2011-2012

INSTRUCTIONS FOR HOUSEHOLDS:

    Part 1: List each child’s name, name of the school and check the box if the child is a foster child, the grade and their

    Eligibility Group Number for SNAP or TANF (if any). Optional (Social Security Number, Student I.D. or Date of

    Birth). Foster children no longer need to be on a separate application.

Part 2: If a child in your household is homeless, migrant or runaway, check the appropriate box and call the school’s

    administrative offices at the telephone number provided.

Part 3: Follow these instructions to report last month’s household income.

    Column 1 Name: List the last, first and middle initial of each person living in your household, related or not

    (such as grandparents, other relatives or friends). You must include yourself and all children. Attach another

    sheet of paper if needed.

    Column 2 Income and how often it is received: For each person who receives income, write the amount

    received and how often it is received weekly (W), every 2 weeks (E), twice a month (T) or monthly (M).

    Employment Income: List the gross income for each person. It is not the same as take-home pay. Gross

    income is the amount earned before taxes and deductions. It should be listed on your pay stub or your

    employer can tell you. Next to the amount, write how often you receive it weekly (W), every 2 weeks (E), twice

    a month (T) or monthly (M).

    Other Income: List the amount each person receives from all other sources. Include welfare, child support,

    alimony, pensions, retirement, Social Security, Worker’s Compensation, unemployment, strike benefits,

    Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), disability benefits, regular contributions

    from people who do not live in your household and ANY OTHER INCOME. Report net income for self-owned

    business, farm or rental income. Next to the amount, write how often the person receives it.

    Column 3 Check if no income: If the person does not have any income, check the box.

    Part 4: An adult household member must sign the form and provide the last four digits of his or her Social Security

    Number or mark the box if he or she doesn’t have one. The adult household member signing the form prints their

    name, home phone number, work phone number and mailing address.

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 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.

     Non-Discrimination Statement: This explains what to do if you believe you have been treated unfairly. 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 Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired 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.

     2011-2012 English Multi-Child Application

    Multi-Child Free and Reduced-Price School Meals Application for 2011-2012

    Local Education Agency Lago Vista ISD

    Part 1. Children in School

    Names of all children in school School Name Social Security #, Grade Eligibility Group # (Last, First, Middle Initial) Student I.D. or for SNAP or TANF Check box if a foster child Date of Birth (if any) (legal responsibility of welfare (OPTIONAL) agency or court)

    1. 2. 3. 4. 5. 6. If you listed an Eligibility Group # for SNAP/TANF, skip to Part 4.

    Part 2. Homeless, Migrant or Runaway

    If any child you are applying for is homeless, migrant or a runaway, check the appropriate box and call your school’s administrative

    offices at ( ) - . Homeless Migrant Runaway

    Part 3. Household Members and Gross Income From Last Month (List each person in the household. For each person who

    receives income, write the amount received and how often it is received.)

    1. Name. (List everyone in 2. Income and how often it is received. 3. Check if NO household, including How Often = Weekly (W), Every 2 Weeks (E), Twice a Month (T), Monthly (M) Income. students listed in Part 1.)

     Earnings Welfare, Pensions, How How How How from work child retirement, Other before Often support, Often Social Often Often deductions alimony Security Example: Smith, Jane B. $200 W $50 E 1. 2. 3. 4. 5. 6. 7. Part 4. Signature and Social Security Number (Adult must sign.)

    An adult household member must sign the application. If Part 3 is completed, the adult signing the form must also list the last 4 digits of his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on the “Instructions for Applying” page.) I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted.

    Sign here: Date: Social Security Number: XXX -XX - ; I do not have a Social Security Number. Printed Name: Home Phone: Work Phone: Mailing Address: City: State: Zip:

    Do not fill out this part. For school use only. Multiple income frequencies must be converted to annual amounts and combined to determine household income. Do not convert if only one income frequency is provided by the household. If converting income to annual, round only the final number. Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12

    Household Income: Household Size: SNAP/TANF: Date Withdrawn: Meal Eligibility: Free: Reduced: Denied: Reason: Temporary: Free: Time Period: (expires after days) Reviewing Official’s Signature: Date:

    Confirming Official’s Signature: Follow-up Official’s Signature: Date:

    Multi-Child Free and Reduced-Price School Meals Application for 2011-2012 continuation sheet Part 1. Children in School continuation sheet

    Names of all children in school School Name Social Security #, Grade Eligibility Group # (Last, First, Middle Initial) Student I.D. or for SNAP or TANF Check box if a foster child Date of Birth (if any) (legal responsibility of welfare (OPTIONAL) agency or court)

    7.

    8.

    9.

    10.

    11.

    12.

    13.

    14.

    15.

    Part 3. Household Members and Gross Income From Last Month (List each person in the household. For each

    person who receives income, write the amount received and how often it is received.)

    1. Name. (List everyone in 2. Income and how often it is received. 3. Check household, including How Often = Weekly (W), Every 2 Weeks (E), Twice a Month (T), Monthly (M) if NO students listed in Part 1.) Income.

    Earnings Welfare, Pensions, How How How How from work child retirement, Other before Often support, Often Social Often Often deductions alimony Security

    8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

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 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.

    Non-Discrimination Statement: This explains what to do if you believe you have been treated unfairly. 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 Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing

    impaired 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.

     2011-2012 English Multi-Child Application

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