By Marilyn Cox,2014-07-08 10:59
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    Exhibit A

     Check here if you received BREMERTON SCHOOL DISTRICT


Complete, sign and return this application to your child’s kitchen.

    1. List all students living with you that are attending school. If the student is a foster child, indicate this by placing an “x” in the appropriate box. Include any personal income received by

    the student and make an “x” in the correct box for how often it is received. If you have written a case number for any of your children, skip to Section 4. However, if you have written a

    case number only for the foster child and want to apply for all students in the household, you must proceed to Section 2.

    If any child you are applying for is homeless, migrant, or a runaway, check the appropriate box and call your school. Homeless Migrant Runaway Student’s Last Student’s First Date of Student Does the student receive Basic Food, TANF or School GradeMI Birth Income Name Name FDPIR? If YES, you must list a case number. Weekly

    Foster Child Every 2 Weeks $ Yes-Case # Twice a Month $ Yes-Case #

    Monthly $ Yes-Case #

     $ No Income Yes-Case #

     $ Yes-Case #

    2. List the names of all other household members - Enter income and CHECK how often it is received. If you write a case number for another household member, skip to

    Section 4. However, if the case number is only for the foster child(ren), you must proceed to Section 3.

     Pensions, Does any household Earnings Any Other Names of ALL other household members Retirement, member receive Basic Monthfrom work Child Support, Income Not (do not include names of students listed Social Food, TANF, or FDPIR? (before any Alimony Already WeeklyWeeklyWeeklyWeeklyMonthly above) Security If YES, you must list a deductions) Listed Every 2 Weeks Every 2 Weeks Every 2 Weeks Every 2 Weeks (SSI) case number. Foster Child Twice a Month Twice a Month Twice a Month Twice a $ $ $ $ No Income Monthly Monthly Monthly $ $ $ $

     $ $ $ $

     $ $ $ $

     $ $ $ $

    3. Total Household Members (include all people living in your household):

    4. Signature and Social Security Number I certify that all of the above information is true and correct and that all of the income is reported and/or the Basic Food or TANF/FDPIR case

    number is reported correctly. I understand that this information is being given for the receipt of federal funds; that school officials may verify the information on the application and that

    deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws.

     Last 4 digits of your social security number:

    Printed Name of Adult Household Member OR, if you do not have a social security number, check the box:

Mailing Address Street Address Adult Household Member Signature Date

    City & Zip Code Home Phone Work/Cell Phone Email Address

    FORM SPI NSLP Exhibit A (Rev. 06/11) Page 1

    Exhibit A 5. Children’s Racial and Ethnic Identities (Optional)

    Mark one or more racial identities: Mark one ethnic identity:

     Asian American Indian or Alaska Native Hispanic or Latino

     White Native Hawaiian or Other Pacific Islander Not Hispanic or Latino

     Black, or African American Other

6. Other Benefits Please check the box in front of the programs that you wish to share your child’s free or reduced price meal status with in order to qualify for a reduction

    in fees: Sport/Athletic Fees College Bound Full-day Kindergarten

By signing below, I allow the information contained on this application to be shared with the other program(s) I have indicated.

Parent/Guardian Signature Date

    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 (Basic Food), 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.

     ANNUAL INCOME CONVERSION: Weekly x 52; Every Two Weeks x 26; Twice a Month x 24; Monthly x 12. Do NOT convert to annual income unless household reports multiple pay frequencies.


     Basic Food/TANF/FDPIR Household Total Household Size

     Income Household Total Household Income $

     Foster Child (categorically free) Income Approved by (check one): weekly every two weeks twice a month monthly annual


     Free Meals Free Meals Reduced-Price Income Over Allowed Amount

     Reduced-Price Meals Incomplete/Missing Information

    Date Temporary Approval Expires: Other:

Date Notice Sent Signature of Approving Official Date

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