FREE AND REDUCED PRICE SCHOOL MEALS FAMILY APPLICATION APPLICATION #_________

    Complete one application per household and one application for each foster child.

    Part 1. Children in School (Use a separate application for each foster child.)

     Food Stamp (not EBT card #) Names of all children in Richland School District 2 School Name Grade or TANF Case # (if any) (First, Middle Initial, Last)

    ; ;

Part 2. If the child you are applying for is a homeless, migrant, or a runaway, check the appropriate box and call

     Cindy Martin at 419-2316. ？;Homeless ？ Migrant ？;Runaway

    Part 3. Foster Child If this application is for a child who is the legal responsibility of a welfare agency or court, check this box ？ and

     then list the amount of the child’s personal use monthly income: $________ Write “0” if foster child has no personal use income. Skip to Part 5. Part 4. Total Household Gross Income—You must tell us how much and how often. ;

    ？;； Name ？ Last month’s income and how often it was received (Check correct box for each income to indicate Check (List everyone in household.);how often received); if ;

     NO Example: $10/monthly $100/twice a month $100/every other week $100/weekly MO；;;;;;2/MO； BW ； (BI-WEEKLY) WK ；;Income;;Earnings from work before Welfare, child support, alimony Pensions, retirement, Social deductions Security Other 1. ;;;;

    $_____________$______________ $_______________ $______________ MO；;2/MO； BW；;WK； MO；;2/MO； BW；;WK； MO；;2/MO；BW；;WK； MO ； 2/MO ；;BW ；;WK ；

    2.

    $_______________ $______________ $________________$___________ MO ；;2/MO ；;BW ；;WK ； MO ；;2/MO ；BW ；;WK ;； MO ；;2/MO ；BW ；;WK ； MO ；;2/MO ；BW ；;WK ； 3.

    $_______________ $______________ $________________ $___________ MO ；;2/MO ；BW ；;WK ； MO ；;2/MO ；;BW ；;WK ； MO ； 2/MO ；;BW ；;WK ； MO ；;2/MO ；BW ；;WK ； 4.

    $_______________ $______________ $________________$___________MO ；;2/MO ；;BW ；;WK ； MO ；;2/MO ；BW ；;WK ； MO ；;2/MO ；;BW ；;WK ； MO ；;2/MO ；BW ；;WK ； 5.

    $_______________ $______________ $________________ $___________MO ；;2/MO ；;BW ；;WK ； MO ；;2/MO ；BW ；;WK ； MO ；;2/MO ；;BW ；;WK ； MO ；;2/MO ；BW ；;WK ； 6.

    $_______________ $______________ $________________ $___________ MO ；;2/MO ；;BW ；;WK ； MO ；;2/MO ；BW ；;WK ； MO ；;2/MO ；;BW ；;WK ； MO ；;2/MO ；BW ；;WK ； 7.

    $_______________ $______________ $________________$___________ MO ；;2/MO ；;BW ；;WK ； MO ；;2/MO ；BW ；;WK ； MO ；;2/MO ；;BW ；;WK ； MO ；;2/MO ；BW ；;WK ； Part 5. Signature and Social Security Number (Adult must sign.) An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement in parent letter.) 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 the information provided on this application may be used to verify my household's eligibility for benefits in the National School Lunch Program with Medicaid agencies as part of the state's participation In the Medicaid Verification Study. I understand that if I purposely give false information, my children may lose meal benefits,

    and I may be prosecuted. Signature:x__________________________Print name:_______________________________ Address:__________________________PhoneNumbers(home)___________________(cell)______________(work)_______________ Social Security Number: __ __ __ - __ __ - __ __ __ __ ？ I do not have a Social Security Number Part 6. Children’s racial and ethnic identities (optional) Mark one or more racial identities: American Indian or Alaska Native, Black or African American, White, Asian, Native Hawaiian or Other Pacific Islander, Other: _________________Mark one ethnic identity: Hispanic or Latino Not Hispanic or Latino

    Don’t fill out this part. This is for school use only.

    Annual Income Conversion: Weekly x 52 Every 2 Weeks x 26 Twice A Month x 24 Monthly x 12 Total Income: $___________ ？Per: Week; ;？Every 2 Weeks; ？Twice a Month; ？ Month; ？ Year Household Size: ______ Categorical Eligibility: ____ Date Withdrawn: ___________ Eligibility: Free___ Reduced___ Denied___Reason: _______ Temporary: Free _____ Reduced ______ Time Period: __________________________ (expires after _____ days) Determining Official’s Signature: __________________________________________________Date:_______________________________

    Confirming Official’s Signature: _____________________________________________ Date: __________________________ Follow-up Official’s Signature: _______________________________________________ Date:__________________________

     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, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer. Application July 1, 2008-June 30, 2009, Page 1 of 2

    INSTRUCTIONS FOR APPLYING

If your household gets FOOD STAMPS or TANF, follow these instructions:

    Part 1: List child(ren)’s name, school, grade, and Food Stamp or TANF case number.

    Part 2: Check the appropriate box, if any.

    Part 3: Skip this part.

    Part 4: Skip this part.

    Part 5: Sign the form. A Social Security Number is not necessary.

    Part 6: Answer this question if you choose to.

    Check the appropriate box and contact your school food service director. Fill out application by following instructions for ALL OTHER HOUSEHOLDS.

If you are applying for a FOSTER CHILD, follow these instructions:

    Part 1: Use a separate application for each foster child. List the child’s name, school, and grade.

    Part 2: Skip this part.

    Part 3: Check the box and list the child’s personal use monthly income, if any.

    Part 4: Skip this part.

    Part 5: Sign the form. A Social Security Number is not necessary.

    Part 6: Answer this question if you choose to.

All OTHER HOUSEHOLDS, follow these instructions:

    Part 1: List each child’s name, school, and grade.

    Part 2: Check the appropriate box, if any.

    Part 3: Skip this part.

    Part 4: Follow these instructions to report total household income from last month.

     Column 1-Name: List the first and last name of each person living in your household, related or not (such as

    grandparents, other relatives, or friends). You must include yourself and all children living with you. Attach another sheet of paper if you need to.

     Column 2-Gross income last month and how often it was received: Next to each person’s name list each

    type of income received last month and how often it was received. For example, Earnings from work: List the gross

    income each person earned from work. This is not the same as take-home pay. Gross income is the amount earned

    before taxes and deductions. The amount should be listed on your pay stub, or your boss can tell you. Next to the amount, write how often the person got it (weekly, every other week, twice a month, or monthly). All other income: List

    the amount each person got last month from welfare, child support, alimony, (second column) pensions, retirement, Social Security, (third column), and ALL OTHER INCOME SOURCES (fourth column). In the All Other column include Workers’ 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 got it. If you are in the Military Housing Privatization Initiative do not include this housing allowance.

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

    Part 5: An adult household member must sign the form and list his or her Social Security Number, or mark the box if he or she doesn’t have one.

    Part 6: Answer this question if you choose to.

    Application July 1, 2008-June 30, 2009, Page 2 of 2