By John Simpson,2014-07-08 10:51
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Dear Parent/Guardian: The Lead-Deadwood School District offers healthy meals every day that it is open as part of our participation in the U.S. Department of Agriculture’s (USDA) Child Nutrition Programs. Meal pricing for 2011-2012 is below: th; Student’s Pre-K-5 grade may purchase lunch for $1.90. thth; Student’s 6-12 grade may purchase lunch for $2.15.

    ; Breakfast for ALL grades will be $1.10.

    ; Students may qualify for free or reduced price meals: Reduced lunch is $.40 & Reduced breakfast is $.30.

    ; Adult price breakfast is $1.35 and Adult price lunch is $2.65.

    ; $.35 for Milk.

     To apply for free or reduced price meals, use the Free and Reduced Price School Meal Application attached AND send to:

    LaVonne Wold, Food Service Director, 320 S Main St, Lead, SD 57754 Ph 605.717.3890 ext.2132


1. Who can receive free meals without providing income information?

    ; Children in households receiving SNAP, TANF, or FDPIR. If you received a letter from Social Services or an Interagency Notification from the commodity warehouse, turn that into the school/center instead of filling out an application. You can write the names of other children from your household on that letter and they will receive free meals, too. If you did not receive an FDPIR Notification, you can ask for one from the certifier.

    ; Foster children (See #8 below.) and children enrolled in Head Start are also eligible for free meals.

    ; Homeless, runaway and migrant children usually are eligible for free meals. Please call the school's homeless liaison or migrant coordinator to see if your child (ren) qualifies, if you have not been told already that they will receive free meals.

    2. Who needs to fill out an application to receive free or reduced price meals?

    ; If you do not have your notice from Social Services or FDPIR, fill out an application and write your case number on it. Turn that into the school/center.

    ; If your household income is within the limits on the Income Guidelines Chart with this application, fill out an application.

    ; Children in households who receive WIC or Medicaid may be eligible for free or reduced price meals. Please fill out an application and list your income and family members.

    3. Do I need to fill out an application for each of my children? Complete and submit one application for all children from your household. We cannot approve a form that is not complete, so be sure to read the instructions carefully and fill out all required information.

    4. Who can receive reduced price meals? Your children can receive low cost meals if your household income is within the reduced price limits on the Income Guidelines Chart, shown on this application.

    5. May I fill out a form if someone in my household is not a U.S. citizen? Yes. You or your children do not have to be U.S. citizens to qualify for meal benefits.

    6. Who should I include as members of my household? You must include everyone in your household (such as grandparents, other relatives, or friends who live with you) who shares income and expenses. You must include yourself and all children who live with you. You also may include foster children who live with you.

    7. What should I report as income? The income you report must be the total gross income listed by source for each household member received last month. If last month’s income does not accurately reflect your circumstances, you may provide a projection of your monthly income. If no significant change has occurred, you may use last month’s income as a basis to make this projection. Once properly approved for free or reduced price benefits, whether through income or by providing a current SNAP, TANF, FDPIR case number, you will remain eligible for those benefits for an allotted time period. You may visit with a school/center official to get the exact date the benefits will expire. List the amount that is usually listed on your paystubs and how often you are paid. For example, if you normally receive $1000 each month, but you missed some work last month and only received $900, put down that you make $1000 per month. Only include overtime pay if received on a regular basis.

    8. What if I have foster children? Foster children that are under the legal responsibility of a foster care agency or court are eligible for free meals. Any foster child in the household is eligible for free meals regardless of income. Households may include foster children on the application, but are not required to include payments received for care of the foster child as income. Households wishing to apply for meal benefits for foster children should contact: LaVonne Wold, FS Director, 320 S Main St, Lead SD 57754

    9. We are in the military, do we include our housing, food, or clothing allowances and supplemental allowances as income? If your housing is

    part of the Military Housing Privatization Initiative and you receive the Family Subsistence Supplemental Allowance, do not include these allowances as income. Also, in regard to deployed service members, only that portion of a deployed service member’s income made available by them or on their behalf to the household will be counted as income to the household. Combat Pay, including Deployment Extension Incentive Pay (DEIP) is also excluded and will not be

    counted as income to the household. All other allowances must be included in your gross income. 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 deployment and it wasn’t received before

    deployment, combat pay is not counted as income. Contact your school for more information.

    10. Will you tell anyone else about the information on my form? We will use the information on your form to decide if your children should receive free or reduced price meals. We may inform officials associated with other child nutrition, health, and education programs of the information on your form to determine benefits for those programs or for funding and/or evaluation purposes.

    11. Will the information I give be checked? YES. We may ask you to send written proof to verify the information you submitted on the form. 12. What if I do not agree with the school/center's decision about my application? You should talk to school/center officials by calling or writing to : Dr Dan Leikvold, Superintendent, 320 S Main, Lead SD 57754 Ph 605.717.3890 ext.2101

13. If I don’t qualify now, may I apply again later? YES. You may apply at any time during the year if your household size increases, income decreases, or if

    you start receiving SNAP, FDPIR, or TANF. If you are temporarily laid off or temporarily disabled so you can’t work, children may be able to receive free or reduced price meals during that time.

    14. What if my child needs special foods? The school/center will make substitutions to the regular meal pattern for children whose disability restricts their

    diet when a physician certifies that disability. The staff may choose to make substitutions for individual children who do not have a disability, but who cannot eat a food item due to medical or other special dietary needs that are supported by a certified medical authority. These cases will be handled on a case-by-case basis. Please call the school/center food service department for further information to request the special diet. 15. 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, contact the local assistance office.

    If you have other questions or need help, please call 717-3890. Sincerely,

    ; Dr Dan Leikvold, Superintendent


    If your household receives SNAP, FDPIR, OR TANF but you don’t have a letter from Social Services or Notice of Action from FDPIR, follow these instructions:

    Part 1: List each child’s name, school/center, age, and/or grade, and mark “Y” if any of the children are foster children. Part 2: List the SNAP, FDPIR, and/or TANF case number. Part 3: Skip this part. Part 4: Skip this part. Part 5: Sign the form. A Social Security Number is not necessary.

     If you are applying for a child who is homeless, migrant, or a runaway check the appropriate box in Part 3 and call your school’s homeless contact, or migrant coordinator.

    ALL OTHER HOUSEHOLDS follow these instructions:

    Part 1: List each child’s name, school/center, age, and mark “Y” if any of the children are foster children. Part 2: Skip this part. Part 3: Skip this part. Part 4: Follow these instructions to report total household income from last month. Column AName: 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. College students away at school may still be part of the household in some circumstances. If the student is counted in the household that student’s income must also be included. Attach another sheet of paper if you need to. Column BList income and how often it was received: List the types of income your household receives, how much you are paid each payday, and how often you are paid. Income for last month list how much you received each pay day and how often you were paid. Example: $200/monthly or $92.30/twice a month or $100/every other week $46.15/weekly

    ; Employment income: List the gross income each person earned. 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 boss can tell you. Next to the amount, write how often you received it (weekly, every other week, twice a month, or monthly).

    ; Welfare, Child Support, Alimony - Include welfare, child support, alimony you receive.

    ; Pensions Retirement, Social Security: Include these as well as Worker’s Compensation, unemployment, strike benefits, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), disability benefits,

    ; Farm/Other Income: Include regular contributions from people who do not live in your household and all other sources not previously covered. For farm income, see the worksheet on the back of the application. Next to the amount, write how often the person was paid. Column CCheck if no income: If the person, including children, does not have any income, check the box. Part 5: An adult household member must sign the form and list only the last four digits of his or her Social Security Number, or mark the box if he or she does not have a Social Security Number. Part 6: Participant’s ethnic and racial identities. This section is optional. If you leave it blank, the application will be processed without the information. Filling this out or leaving it blank does not affect the child’s eligibility. If you leave this blank, a visual identification of each child’s race and ethnicity will be made and recorded in the data system.

    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, S.W., 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. 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 the participant 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 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 for the participant or other (FDPIR) identifier 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 the participant is eligible for free or reduced price meals, and for administration and enforcement of the Program.

    (Effective July 1, 2011 June 30, 2012)

     Annually Monthly Every 2 Twice a Weekly

    weeks month

    Household Size

    1 20,147 1,679 775 840 388

    2 27,214 2,268 1,047 1,134 524

    3 34,281 2,857 1,319 1,429 660

    4 41,348 3,446 1,591 1,723 796

    5 48,415 4,035 1,863 2,018 932

    6 55,482 4,624 2,134 2,312 1,067

    7 62,549 5,213 2,406 2,607 1,203

    8 69,616 5,802 2,678 2,901 1,339

    For each extra member, 7,067 589 272 295 136 add

Look at the Income Guidelines chart. Find your household size. HOUSEHOLD is: All persons, including parents, children, college students,

    grandparents, and all people related or unrelated who live in your home and share living expenses. Find your total household income. TOTAL HOUSEHOLD INCOME is the income each household member received last month before taxes. This includes wages, social security, pension, unemployment, welfare child support, alimony, and any other cash income. In most cases, foster children are eligible for free and reduced price meals regardless of your income. If you have foster children living with you, look at Part 1 on the application. If you have more questions about applying for them, please contact us.

    DETERMINING INCOME - If a household reports income sources at more than one frequency, the preferred method is to annualize all income by multiplying weekly income by 52, income received every 2 weeks by 26, income received twice a month by 24, and income received monthly by 12. Do not round the values resulting from each conversion.

    To figure monthly income for farm/self-employed: The information to figure income from private business operation is to be taken from your U.S. Individual Income Tax Return Form 1040. Write the numbers from the corresponding tax form lines in the spaces below. Divide the total

    by 12 and write it on the application in the earnings column as monthly, or list the whole amount as yearly. If it is a negative number, write it as zero on the application. All other income on lines 7 through 22 of the tax form must be listed separately for the person who earned it. Net loss carryover cannot be used to decrease the household income.

    Proprietorship Income Farm Income Partnership Income

    Line 12 $ _______________ Line 13 $ _______________ Line 13 $ _______________

    Line 13 $ _______________ Line 14 $ _______________ Line 14 $ _______________

    Line 14 $ _______________ Line 17 $ _______________ Line 17 $ _______________

    TOTAL $ _______________ Line 18 $ _______________ TOTAL $ _______________

    TOTAL $ _______________


    Earnings from Work Other Monthly Income/Self-employment Pensions/Retirement/Social Security

    Wages/salaries/tips Disability benefits Pensions

    Strike benefits Cash withdrawn from savings Supplemental Security Income

    Unemployment compensation Interest/dividends Veteran’s payments

    Worker’s compensation Income from estates/trusts/investments Social Security

    Net income from self-owned business, Regular contributions from persons not

    day care business or farm living in the same household Children’s Income

     Net royalties/annuities/net rental income Do not include income from a child’s Welfare/Child Support/Alimony Any other income occasional work such as lawn mowing, Public assistance payments babysitting, cleaning walks, etc. A Alimony/child support payments child’s income from regularly

     scheduled jobs must be included.



    To apply for free or reduced price meals, fill out this application and sign your name.

    Part 1. Children’s Names Child’s Name School or Center Foster Age Child’s Name School or Center Foster Age 1. 4. 2. 5. 3. 6. Part 2. Households receiving SNAP, TANF, or FDPIR: If any member of your household is NOW receiving SNAP,TANF, and FDPIR, list the CASE NUMBER. Fill out Sections 1, 2, and 5. The application MUST have the signature of an adult.

    SNAP Case Number: TANF Case Number: FDPIR Case Number:

    Part3. Is this child a migrant, homeless, or runaway? If the child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your school’s homeless liaison or migrant coordinator Homeless Migrant Runaway Part 4. Total Household Income from Last Month You must tell us how much and how often

    A. Name B. Income list how much you get each pay day and how often you get paid C. Check (List everyone in household) Example: $100/month $100/twice a month $100/ every other week $100/weekly if No income

     Earnings from work before Welfare, child support, Pensions, retirement, Farm/Other deductions alimony Social Security

     $ / $ / $ / $ /

     $ / $ / $ / $ /

     $ / $ / $ / $ /

     $ / $ / $ / $ /

     $ / $ / $ / $ /

     $ / $ / $ / $ /

     $ / $ / $ / $ /

     $ / $ / $ / $ / 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 only 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 page.) I certify (promise) that all information on this application is true and that all income is reported. I understand that the school/center will get Federal funds based on the information I give. I understand that officials may verify (check) the information. I understand that if I purposely give false information, the children may lose meal benefits, and I may be prosecuted.

    Sign here: X

     I do not have a Social Security Number Last 4 digits of Social Security Number: ____ ____ ____ ____ Work Printed Name: Home Phone: Phone: Home Address: Mailing Address:

    City: State: Zip Code: Date: Part 6. Participant’s ethnic and racial identities (optional) Mark one ethnic identity: Mark one or more racial identities: ; Hispanic or Latino ; Asian ; American Indian or Alaska Native ; White ; Not Hispanic or Latino ; Native Hawaiian or Other Pacific Islander ;Black or African American

     FOR LD-DWD SCHOOL DISTRICT ONLY SNAP / FDPIR / TANF or other eligible program household categorically eligible free: Yes No

    Total monthly income: Eligibility Classification: Free Reduced Price Paid Household Size: Not Eligible: Over income Incomplete information

     Temporary Free Eligible Until

     Date Notification Sent: Change in Status Date: Date Withdrawn:

     Signature of Determining Official: Date:

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