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INSTRUCTIONS FOR SCHOOL DISTRICTS

By Joyce Weaver,2014-07-08 09:13
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FREE AND REDUCED PRICE SCHOOL MEALS APPLICATION AND VERIFICATION FORMS ... HOUSEHOLDS WITH CHILDREN WHO ARE APPROVED FOR FREE OR REDUCED PRICE BENEFITS MAY BE ...

    FREE AND REDUCED PRICE SCHOOL MEALS

    APPLICATION AND VERIFICATION FORMS

     SCHOOL YEAR 2012-2013

    INSTRUCTIONS FOR SCHOOL DISTRICTS

    This packet contains:

    Required information that must be provided to households:

    ; Letter to Households

    ; Free and Reduced Price School Meals Application

    ; Notice of Approval / Denial*

    ; Direct Certification Notice of Approval

    ; Migrant / Homeless / Runaway / Foster / Head Start / Even Start Notice of

    Approval

    Verification of eligibility information materials:

    ; Notification of Selection for Verification of Eligibility

    ; Letter of Verification Results

    ; Verification Tracker

    ; Verification Timelines

    Optional application-related materials that may be provided to households:

    ; Sharing Information With Other Programs

    The pages are designed to be printed on 8?” by 11” paper. Some pages may be printed front and back. You will need to identify the benefits that are offered in your school, such as Afterschool Snacks. The [Bold bracketed fields] indicate where you need to

    insert school district specific information. For example, you must include your district’s no-charge telephone number for verification assistance on the verification materials. If

    you make additional changes, you must submit your application package to Arkansas Department of Education, Child Nutrition Unit (ADE, CNU) for approval prior to public distribution.

    This prototype application package includes information regarding the exclusion of housing allowance for those in the Military Housing Privatization Initiative. If this is not pertinent to your school district, please modify as appropriate.

    If you have questions, contact:

    Child Nutrition Unit

    Arkansas Department of Education

    2020 West Third, Suite 404

    Little Rock, AR 72205-4465 * All households must be notified of their eligibility status. Households with children who are denied benefits must be given written notification of the denial. The notification must advise the household of the reason for the denial of benefits, the right to appeal, instruction on how to appeal and a statement that the family may re-apply for free and reduced price meal benefits at any time during the school year. Households with children who are approved for free or reduced price benefits may be notified in writing or verbally. Instructions to School Districts 2012-13 School Year Page 1 of 1

[Insert School District Letterhead]

Dear Parent/Guardian:

    Children need healthy meals to learn. [Name of School] offers healthy meals every school day. Breakfast cost [$]; lunch cost [$]. Your

    children may qualify for free meals or for reduced price meals. Reduced price is [$] for breakfast and [$] for lunch.

    1. Do I need to fill out an application for each child? No. Complete the application to apply for free or reduced price meals. Use one Free and Reduced Price School Meals Application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to: [name, address, phone number]. 2. Who can get free meals? All children in households getting Supplemental Nutrition Assistance Program (SNAP) benefits (formerly the Food Stamp Program) can get free meals regardless of your income. Also, your children can get free meals if your household gross

    income is within the free limits on the Federal Income Eligibility Guidelines.

    3. Can foster children get free meals? Yes, foster children that are under the legal responsibility of a foster care agency or court, are eligible for free meals regardless of income.

    4. Can homeless, runaway and migrant children get free meals? Yes, children who meet the definition of homeless, runaway or migrant qualify for free meals. If you haven’t been told your children will get free meals, please call or email [school, homeless liaison

    or migrant coordinator] to see if your child(ren) qualify.

    5. Who can get reduced price meals? Your children can get low cost meals if your household income is within the reduced price limits on the Federal Income Eligibility Chart, shown on this application.

    6. Should I fill out an application if I got a letter this school year saying my children are approved for free or reduced price meals? Please read

    the letter you got carefully and follow the instructions. Call the school at [phone number] if you have questions.

    7. My child’s application was approved last year. Do I need to fill out another one? Yes. Your child’s application is only good for that school year and for the first few days of this school year. You must send in a new application unless the school told you that your child is eligible for free meals for the new school year.

    8. I get WIC. Can my child(ren) get free meals? Children in households participating in WIC may be eligible for free or reduced price meals. Please fill out an application.

    9. Will the information I give be checked? Yes, we may ask you to send written proof.

    10. If I don’t qualify now, may I apply later? Yes. You may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free or reduced price meals if the household income drops

    below the income limit.

    11. What if I disagree with the school’s decision about my application? You should talk to school officials. You also may ask for a hearing by calling or writing to: [name, address, phone number, e-mail].

    12. May I apply if someone in my household is not a U.S. citizen? Yes. You or your child(ren) do not have to be a U.S. citizen to qualify for free or reduced price meals.

    13. Who should I include as members of my household? You must include all people living in your household, related or not (such as grandparents, other relatives, or friends) who share income and expenses. You must include yourself and all children who live with

    you. If you live with other people who are economically independent (for example, people who you do not support, who do not share

    income with you or your children, and who pay a pro-rated share of expenses), do not include them. 14. What if my income is not always the same? List the amount that you normally get. For example, if you normally get $1000 each month, but you missed some work last month and only got $900, put down that you get $1000 per month. If you normally get overtime,

    include it, but not if you get it only sometimes. If you have lost a job or had your hours or wages reduced, use you current income.

    15. We are in the military, do we include our housing allowance as income? If you get an off-base housing allowance, it must be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing

    allowance as income.

    16. My spouse is deployed to a combat zone. Is the combat pay counted as income? No, if the combat pay is received in addition to the basic pay because of the deployment and it wasn’t received before the deployment, combat pay is not counted as

    income. Contact your school for more information.

    17. My family needs more help. Are there other programs we might apply for? To find out how to apply for SNAP or other assistance benefits, call or go to the Department of Human Services (DHS) office in any county and ask for an application form. The

    application is available for printing online at:

    http://humanservices.arkansas.gov/dco/dco_docs/DCO-215%20Request%20for%20Assistance%201108.pdf 18. The free and reduced lunch statistics allow our schools to receive technology funding from the federal government. It provides

    access to the Internet and distance learning services. Please help us by returning this form. If you have other questions or need help, call [phone number].

    Si necesita ayuda, por favor llame al teléfono: [phone number].

    Si vous voudriez d’aide, contactez nous au numero: [phone number].

Sincerely,

[signature] 2012-13 Letter to Household

    INSTRUCTIONS FOR APPLYING

    If your household receives benefits from the Supplemental Nutrition Assistance Program (SNAP),

    formerly the Food Stamp Program, follow these instructions:

    Part 1: List all child(ren)’s attending this district by name, school, grade.

    Part 2: Complete the name of the household member receiving SNAP benefits and the SNAP case number.

    Part 3: Skip this part.

    Part 4: Sign the form. A Social Security Number is not necessary.

    Part 5: Answer this question if you choose to. Mark one box for racial identity and one box for ethnic.

    Part 6: If the household does not want the student’s eligibility information shared with Medicaid or

     ARKids 1st then check this box.

    If NO ONE in your household receives SNAP benefits AND if all child(ren) in your household is/are foster child(ren):

    Part 1: List all the child(ren) in the household attending school at this district by name, school, and grade.

     Check the box for each child(ren) that is the legal responsibility of welfare agency or court.

    Part 3: Skip this part.

    Part 4: Sign the form. A Social Security Number is not necessary.

    Part 5: Answer this question if you choose to. Mark one box for racial identity and one box for ethnic. stPart 6: If the household does not want the student’s eligibility information shared with Medicaid or ARKids 1

     then check this box.

    ALL OTHER HOUSEHOLDS, including households with both foster and non-foster children in the same household and WIC households, follow these instructions:

    Part 1: List each child’s name, school, and grade. Check the box for each child(ren) that is the legal

    responsibility of welfare agency or court.

    Part 2: If the household does not have a SNAP case number skip this part. If a SNAP case number is listed

    skip to Part 4 of this form.

    Part 3: 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) who share income and expenses. You must include yourself and all

    children who live with you. If you live with other people who are economically independent (for example, people

    who you do not support, who do not share income with you or your children, and who pay a pro-rated share of expenses), do not include them.

     Column 2: Gross income last month and how often it was received. Next to each person’s name list each type of income received for the month, and how often the money is received. For example, Earnings from work: List the gross income (not take home pay) each person earned from work. This is not the same as take-

    home pay. Gross income is the amount earned before taxes and other 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 receives the income (for example: weekly, every other week, twice a month, or monthly).

     Column 3: List the amount each person got last month from welfare, child support, alimony,

     Column 4: List the amount each person got last month from pensions, retirement, Social Security Supplemental Security Income (SSI), Veteran’s benefits (VA benefits),

     Column 5: List the amount each person got last month from ALL OTHER INCOME SOURCES. Do not

    include the Department of Defense’s Family and Subsistence Supplemental Allowance (FSSA) as income.

    Include disability benefits, Worker’s Compensation, unemployment, strike benefits and 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 6Check 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 list the last four digits of his or her Social Security

    Number, or mark the box if he or she doesn’t have a Social Security Number.

    Part 5: Answer this question if you choose to. Mark one box for racial identity and one box for ethnic.

    Part 6: If the household does not want the student’s eligibility information shared with Medicaid or

     ARKids 1st then check this box.

     Letter to Household 2012-13

    FREE AND REDUCED PRICE SCHOOL MEALS HOUSEHOLD APPLICATION Part 1. Children in School at this District

    Check if a foster child (legal responsibility of welfare Names of all children in school at this agency or court). If all children listed below are foster Grade School Name district (First, Middle Initial, Last) children, skip to part 4 of this form.

    ;

     ;

     ;

     ;

     ;

     ;

     ; Part 2. SNAP Benefits: If any member of your household receives Supplemental Nutrition Assistance Program (SNAP) benefits, provide the name and case number for any household member that receives benefits and skip to Part 4. If no one receives SNAP benefits, skip to Part 3. Name: ______________________________________________ Case Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Part 3. Total Household Gross Income You must tell us how much and how often B. Gross income and how often it was received A. Name Example: $100/monthly $100/twice a month $100/every other week $100/weekly C. Check Pensions, Retirement, if NO (List everyone in Earnings from work Welfare, child support, Social Security, SSI, VA All Other Income income before deductions alimony benefits Income / How often household) Income / How often Income / How often Income / How often

    ; $______/________ $______/________ $______/________ $______/________

     ; $______/________ $______/________ $______/________ $______/________

     $______/________ $______/________ $______/________ $______/_______ ;

     $______/________ $______/________ $______/________ $______/_______ ;

     $______/________ $______/________ $______/________ $______/_______ ;

     $______/________ $______/________ $______/________ $______/_______ ;

     $______/________ $______/________ $______/________ $______/_______ ;

     $______/________ $______/________ $______/________ $______/_______ ;

     $______/________ $______/________ $______/________ $______/_______ ; Part 4. Signature and Last Four Digits of Social Security Number (Adult Must Sign) An adult household member must sign the application. If Part 3 is completed, the adult signing the form also must list the last four 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 back of this form.) 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: X ________________________________________ Social Security Number: xxx-xx- ___ ___ ___ ___ (last 4 digits only) Print Name: ________________________________________ ; I do not have a Social Security Number Phone Number: _____________________________________ Address: _______________________________________________ Date: _____________________________________________ City, State, Zip: ___________________________________________ Part 5. Children’s racial and ethnic identities. Mark one box in each category (optional). Choose one or more (regardless of ethnicity): Choose one ethnicity: ; Asian ; American Indian or Alaska Native ; Hispanic or Latino ; White ; Native Hawaiian or Other Pacific Islander ; Not Hispanic or Latin ; Black or African American

    Part 6. Disclosure (Optional) ; I do not want school officials to share information from my free and reduced price meal application with Medicaid or the State Children’s Health st Insurance Program (ARKids 1). 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: __________ SNAP* (food stamps): _________ Categorically Eligible: ________ Date Withdrawn: __________ Eligibility: Free _______ Reduced ________ Denied ________ Reason: ___________________________________________ Determining Official’s Signature: ________________________________________________ Determination Date: ______________________ Application 2012-13

     FEDERAL INCOME CHART

     For School Year 2012-2013 Your children may qualify for free Household size Yearly Monthly Weekly or reduced price meals if your $ 20,665 $1,723 $ 398 1

    household income falls within the $ 27,991 $2,333 $ 539 2

    limits on this chart. $ 35,317 $2,944 $ 680 3

     $ 42,643 $3,554 $ 821 4

     $ 49,969 $4,165 $ 961 5

     $ 57,295 $4,775 $1,102 6 $ 64,621 $5,386 $1,243 7 $ 71,947 $5,996 $1,384 8 $ 7,326 $ 611 $ 141 Each additional person:

*SNAP: Supplemental Nutrition Assistance Program (formerly the Food Stamp Program)

    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 last four digits of the social security number of the adult household member 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), case 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.”

     Letter to Household 2012-13

    NOTICE OF APPROVAL/DENIAL

Date_____________

Dear_________________________________________:

    Student Name School

Effective Date: ________________

    Your application for free and reduced price meals for your child(ren) listed above has been:

    _____Approved for free meals

    _____Approved for reduced price meals at $______ for lunch and $______ for breakfast.

    _____Denied for the following reason(s):

    _____Income over the allowable amount

    _____Incomplete application because____________________________________

    _____Other ________________________________________________________

Meals cost [$] for lunch and [$] for breakfast.

    If you do not agree with this decision, you may discuss it with___________________________ (Determining Official) at__________________ (phone number) or at __________________(e-mail address).

    If you wish to review the decision further, you have the right to a fair hearing. To request a fair hearing, call or write the following official:

Name: ___________________________________________

Address: __________________________________________

    Phone Number: ___________________________ E-Mail: ___________________________________

    You may reapply for benefits at any time during the school year. If you are not eligible now, but have a decrease in household income, become unemployed, have an increase in household size, or qualify for Supplemental Nutrition Assistance Program (SNAP) formerly Food Stamp Program, you may fill out another application at that time.

Sincerely,

     Name and Title

    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.” Notice of Approval/Denial 2012-13 Page 1 of 1

    NOTIFICATION OF APPROVAL FOR FREE MEALS

    DIRECT CERTIFICATION

Date____________________

Dear Parent/Guardian:

    The student(s) identified below is/are automatically approved for free school meals based on his/her eligibility for Supplemental Nutrition Assistance Program (SNAP), formerly food stamps.

    Student Name School

    Please do not fill out an application for free or reduced price meals for this/these child(ren). Your child(ren) will receive free meals unless you notify us that you do not want your child(ren) to receive these benefits.

    If there are school age children in the household not listed above, those children are also eligible to receive free meal benefits. One way to ensure that these additional students receive free meal benefits is to complete the attached form and return it to the school district.

    If any of the information listed above is incorrect, or you have any questions, please contact this office at __________________________.

     (Phone Number)

Sincerely,

(Name and title)

    If the box below is checked, please sign and return this portion to the school district. Attention: ************************************************************************************* Right to Refuse Meal Benefits

    ; I do not want my child(ren)__________________________________________to receive free meals.

     (Child(ren) Name(s))

    Parent/Guardian Signature: ___________________________________ 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.” Direct Certification Notice of Approval 2012-13 Page 1 of 1

    Notification to School District of Students Residing in

    Households with Direct Certification Students

    Date:

Dear Parent/Guardian:

    All students residing in the same household as students who are automatically approved for free school meals through Direct Certification are also eligible to receive free meal benefits. If there are students living in the same household with students listed on the attached NOTIFICATION OF APPROVAL FOR FREE MEALS DIRECT CERTIFICATION letter that are not listed on the approval letter these additional students are also eligible to receive free meal benefits.

    One way to ensure that the [School District name] School District extends the free meal benefits to all eligible students is for the household to complete PART B of this form and return it to: [name,

    address, phone number].

    If this form is completed there is no need to complete a Free or Reduced Price Meal Application for these children.

PART A:

    Student(s) on the Direct Certification Notification letter:

    Student Name (First, Middle Initial, Last) School Grade

PART B:

    Additional students residing in household with above listed students:

    Student Names (First, Middle Initial, Last) School Grade

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.”

Signature of Parent/Guardian

     Optional Direct Certification Additional HH Members 2012-13 Page 1 of 1

    NOTIFICATION OF APPROVAL FOR FREE MEALS

    MIGRANT / HOMELESS / RUNAWAY / FOSTER / HEAD START / EVEN START

Date____________________

Dear Parent/Guardian:

    The student(s) identified below is/are automatically approved for free school meals based on

    his/her status as ______ Migrant _____ Homeless _____ Runaway ______ Foster or his/her

    enrollment in ________ Head Start Program ________ Even Start Program.

    Student Name School

    Please do not fill out an application for free or reduced price meals for this/these child(ren). Your child(ren) will receive free meals unless you notify us that you do not want your child(ren) to receive these benefits.

    If there are school age children in the household not listed above, an application must be completed for them to receive benefits.

    If any of the information listed above is incorrect, or you have any questions, please contact this office at __________________________.

     (Phone Number)

    Sincerely,

(Name and title)

    If the box below is checked, please return this portion to the school district. Attention:

Name: ___________________________________________________

Address: __________________________________________________

    Phone Number: ___________________________ E-Mail: ___________________________________

    *************************************************************************************

    Right to Refuse Meal Benefits

; I do not want my child(ren)________________________________________to receive free meals. (Child(ren) Name(s))

    Parent /Guardian Signature: ___________________________________

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.” Migrant/Homeless/Runaway/Foster/Head Start/Even Start Notice of Approval 2012-13 Page 1 of 1

    WE MUST CHECK YOUR APPLICATION

    We are checking your Free and Reduced Price School Meals Application. Federal rules require that we do this to make sure only eligible children get free or reduced price meals. You must send us information to prove that [names of children] is/are eligible.

    You must send the information we need, or contact [name] by [date], or your child(ren) will stop getting free or reduced price meals.

    School: ______________________________________________

Date: ___________________________

Dear ___________________________:

    If possible, send copies, not original papers. If you do send originals, they will be sent back to you only if you ask.

    1. If you were receiving benefits from the Supplemental Nutrition Assistance Program (SNAP), formerly Food Stamp Program, when you applied for free or reduced price meals, or at any time since then, send us a copy of one of these:

    ; SNAP Certification Notice that shows dates of certification.

    ; Letter from SNAP Office that shows dates of certification for SNAP benefits. ; Do not send your EBT card.

    2. If you get this letter for a homeless, migrant or runaway child, please contact [school, homeless liaison, or migrant coordinator] for help.

    3. If the child is a Foster Child:

    Provide written documentation that verifies the child is the legal responsibility of the agency or court or provide the name and contact information for a person at the agency or court who can verify that the child is a foster child.

    4. If no one in your household receives SNAP benefits:

    Send papers that show the amount of money your household gets from each source of income. The papers you send must show the name of the person who received the income, the date it

    was received, how much was received, and how often it was received. Send information to:

Name: __________________________________________

Address: __________________________________________

Acceptable papers include:

    Jobs: Paycheck stub or pay envelope that shows the amount and how often pay is received; letter from employer stating gross wages and how often you are paid; or if you work for yourself, business or farming papers, such as ledger or tax books.

    Social Security, Pensions, or Retirement: Social Security retirement benefit letter, statement

    of benefits received, or pension award notice.

    Unemployment, Disability, or Worker’s Comp: Notice of eligibility from State employment

    security office, check stub, or letter from Worker’s Compensation’s office.

    Welfare Payments: Benefit letter from welfare agency.

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