FSM1 APPLICATION FOR FREE SCHOOL MEALS Family Ref: 2011-12 ………..………
Revised May 2011
YOUR DETAILS YOUR PARTNER’S DETAILS YOUR CONTACT DETAILS
PLEASE CIRCLE Mr Mrs Ms Miss Mr Mrs Ms Miss Address
**DATE OF BIRTH __ __/ __ __/ __ __ __ __/ __ __/ __ __
**NATIONAL Postcode INSURANCE NO.
RELATIONSHIP TO Contact Number(s): CHILD (MUM/DAD)
** YOU MUST COMPLETE THIS INFORMATION
Office Use Only Benefit Check (；) e-mail address:
TELL US WHICH CHILD/CHILDREN WANT FREE SCHOOL MEALS (SCHOOL AGE CHILDREN ONLY)
DATE OF DATE THAT CHILD NAME OF SCHOOL THAT FIRST NAME SURNAME BIRTH AGE STARTS/STARTED CHILD IS ATTENDING (dd/mm/yy) THIS SCHOOL
DECLARATION – To be signed by the parent who is in receipt of one of the qualifying benefits, see overleaf.
I certify that the information given is correct and I agree to inform my Local Authority immediately if this benefit stops or if
any Tax Credit is re-assessed. If for any reason I fail to inform the Local Authority that this benefit has stopped, or that my
Tax Credit has been re-assessed, I understand that I may be required to repay the cost of meals received from the date my benefit ceased or was re-assessed. I also agree to inform the Local Authority immediately if I change my address or if there is any other change in my circumstances.
The information provided will be used to process my claim for Free School Meals. The Council will contact other sources as allowed by the law to verify my initial, and ongoing, entitlement. I understand that the results of any Free School Meal
eligibility check may also be used to assess my entitlement to receive other benefits, for example, home to school transport and board and lodgings for residential school trips. All information will be held securely and in accordance with the Data Protection Act 1998. For further information about how Children’s Services uses personal data please go to the following link: http://www.bournemouth.gov.uk/Education/DP_and_FOI/Data_Protection.asp
NAME (BLOCK CAPITALS)
PLEASE SEE NOTES OVERLEAF
HOW TO APPLY FOR FREE SCHOOL MEALS – 2011/12
What you need to do:
Complete the application form fully. You MUST provide all the information we have asked for so that we 1.
can carry out a benefit check. You do not have to send in evidence of the benefits you receive.
To qualify for Free School Meals, you must be in receipt of one or more of the following benefits: 2.
; Income Support
; Income-Based Job Seeker’s Allowance
; an income-related employment and support allowance
; Support Under Part VI of the Immigration & Asylum 1999
; Child Tax Credit, where your annual income (as assessed by HM Revenues and Customs) does not
If you are entitled to Working Tax Credit you are NOT eligible for Free School Meals.
; The Guarantee Element of State Pension Credit
If your child attends a Bournemouth school please return the completed form to: 3.
Student Support Team
When we receive your completed form:
Once we receive your completed application for Free School Meals we will check your benefit entitlement 1.
with data held by the Department of Work and Pensions, the Home Office and HMRC (Revenue and
Customs) through a central Eligibility Checking System (ECS). If we cannot confirm your entitlement
though this process we will write to you to ask you to provide up-to-date evidence of the benefit you
We will inform you in writing whether or not your child/children are entitled to free school meals and the 2.
date that the meals will start.
We will inform your child’s school by e-mail of the Free School Meal eligibility and the start date so they 3.
have time to order the meal from their supplier/inform their canteen staff.
Your child/children will receive free school meals while you are in receipt of one or more of the qualifying
benefits listed above.
If this benefit stops, or your Tax Credit Award is reassessed, you must inform us [Local Authority] immediately. You may be required to repay the cost of any meals received from the date this benefit is ceased or reassessed.
--------------------------------------------------------------------- Local Authority (LA) contacts for Free School Meal applications: -
Bournemouth LA Poole LA Dorset LA
; 01202 456274 ; 01202 634250 ; 01305 224832