Household Application for Free and Reduced-Price School Meals

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One application per household.

Sources of Income for Children

Sources of Child Income Examples
Earnings from work A child has a regular full or part-time job where they earn a salary or wages
Social Security
- Disability Payments
- Survivor’s Benefits
A child is blind or disabled and receives Social Security Benefits.
A parent is disabled, retired, or deceased, and their child receives Social Security benefits.
Income from person outside the household A friend or extended family member regularly gives a child spending money
Income from any other source A child receives regular income from a private pension fund, annuity, or trust.

 

Sources of Income for Adults

Sources of Adult Income Example(s)
Earnings from work Salary, wages, cash bonuses / Net income from self-employment (farm or business) / If you are in the U.S. Military /
-Basic pay and cash bonuses (do NOT include combat pay, FSSA or privatized housing allowances)
-Allowances for off-base housing, food and clothing
Public Assistance / Alimony / Child Support -Unemployment Benefits -Workers compensation -Supplemental Security Income (SSI)
-Cash assistance from State or local government -Alimony payments-Child support payments -Veteran’s benefits -Strike benefits
Pensions / Retirement / All Other Income -Social Security (including railroad retirement and black lung benefits) -Private pensions or disability benefits -Annuities
-Regular income from trusts or estates -Investment income -Earned interest -Regular cash payments from outside household

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), 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 investigate violations of program rules.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. 

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.) should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http:www.ascr.usda.gov/complaint_filing_cust.htm., and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

Mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410
Fax: (202) 690-7442
Email: program.intake@usda.gov
This institution is an equal opportunity provider
 

 

STEP 1: List ALL Household Members who are infants, children, and students up to and including 12

Definition of Household Member. “Anyone who is living with you and shares income and expenses, even if not related”. Children in Foster care and children who meet definition of Homeless, Migrant or Runaway
are eligible for free meals.

Child #1
Child #2
Child #3
Child #4
Child #5
STEP 2: Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR

If NO > Go to STEP 3. If YES > Write a case number here, then go to STEP 4 (Do not complete STEP 3).

STEP 3: Report income for ALL Household Members (Skip this step if you answered “YES” to STEP 2)

Unsure what income to include here? Flip the page and review the charts titled, “Sources of Income”, for more information. The “Sources of Income for Children” chart will help you with the Child Income section.
The “Sources of Income for Adults” chart will help you with the All Adult Household Members Section.

A. Child Income

Sometimes children in the household earn or receive income. Please include the TOTAL income received by All Household Members listed in STEP 1 here

B. All Adult Household Members

List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total gross income (before taxes) for each source in whole dollars (no cents) only. If they do not receive income from any source, write “0”. If you enter “0” or leave any fields blank, you are certifying (promising) that there is no income to report.

Adult #1
Adult #2
Adult #3
Adult #4
STEP 4: Contact information and adult signature.

"I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal Funds, and that school officials may
verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws”.

Optional: Children’s Racial and Ethnic Identities

We are required to ask for information about your children(s) race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional
and does not affect your child(s) eligibility for free or reduced-price meals.