DearParent/Guardian:

Childrenneedhealthymealstolearn.Yourchildsschooloffershealthymealseveryschoolday.Your
childrenmayqualifyforfreemealsorforreducedpricemeals.
1.

DOINEEDTOFILLOUTANAPPLICATIONFOREACHCHILD?No.YoucanuseoneFreeand
ReducedPriceSchoolMealsApplicationforallstudentsinyourhousehold.Wecannotapprovean
applicationthatisnotcomplete,sobesuretofilloutallrequiredinformation.Returnthecompleted
applicationtooneofyourchildrensschool.

2.

WHOCANGETFREEMEALS?AllchildreninhouseholdsreceivingbenefitsfromtheSupplemental
NutritionAssistanceProgram(SNAP),theFoodDistributionProgramonIndianReservationsor,in
someStatesTemporaryAssistanceforNeedyFamilies(TANF),cangetfreemealsregardlessof
yourincome.Also,yourchildrencangetfreemealsifyourhouseholdsgrossincomeiswithinthe
freelimitsontheFederalIncomeEligibilityGuidelines.

3.

CANFOSTERCHILDRENGETFREEMEALS?Yes,fosterchildrenthatareunderthelegal
responsibilityofafostercareagencyorcourt,areeligibleforfreemeals.Anyfosterchildinthe
householdiseligibleforfreemealsregardlessofincome.

CANHOMELESS,RUNAWAY,ANDMIGRANTCHILDRENGETFREEMEALS?Yes,childrenwho
meetthedefinitionofhomeless,runaway,ormigrantqualifyforfreemeals.Ifyouhaventbeentold
yourchildrenwillgetfreemeals,pleasecalloremailyourchildsschooltoseeiftheyqualify.

4.

5.

WHOCANGETREDUCEDPRICEMEALS?Yourchildrencangetlowcostmealsifyourhousehold
incomeiswithinthereducedpricelimitsontheFederalEligibilityIncomeChart,shownonthis
application.

6.

SHOULDIFILLOUTANAPPLICATIONIFIRECEIVEDALETTERTHISSCHOOLYEARSAYINGMY
CHILDRENAREAPPROVEDFORFREEMEALS?Pleasecarefullyreadtheletteryougotandfollowthe
instructions.Callyourchildsschoolifyouhavequestions.

7.

MYCHILDSAPPLICATIONWASAPPROVEDLASTYEAR.DOINEEDTOFILLOUTANOTHERONE?
Yes.Yourchildsapplicationisonlygoodforthatschoolyearandforthefirstfewdaysofthisschool
year.Youmustsendinanewapplicationunlesstheschooltoldyouthatyourchildiseligibleforthe
newschoolyear.

8.

IGETWIC,CANMYCHILD(REN)GETFREEMEALS?ChildreninhouseholdsparticipatinginWIC
maybeeligibleforfreeorreducedpricemeals.Pleasefilloutanapplication.

9.

WILLTHEINFORMATIONIGIVEBECHECKED?Yesandwemayalsoaskyoutosendwritten
proof.

10. IFIDONTQUALIFYNOW,MAYIAPPLYLATER?Yes,youmayapplyatanytimeduringtheschool
year.Forexample,childrenwithaparentorguardianwhobecomesunemployedmaybecome
eligibleforfreeorreducedpricemealsifthehouseholdincomedropsbelowtheincomelimit.

FreeandReducedPriceSchoolMealsApplication
LettertoHouseholds
Page1of2

11. WHATIFIDISAGREEWITHTHESCHOOLSDECISIONABOUTMYAPPLICATION?Youshouldtalk
toschoolofficials.Youalsomayaskforahearingtohavethedecisionreviewed.
12. MAYIAPPLYIFSOMEONEINMYHOUSEHOLDISNOTAU.S.CITIZEN?Yes.Youoryour
child(ren)donothavetobeU.S.citizenstoqualifyforfreeorreducedpricemeals.
13. WHOSHOULDIINCLUDEASMEMBERSOFMYHOUSEHOLD?Youmustincludeallpeoplelivingin
yourhousehold,relatedornot(suchasgrandparents,otherrelatives,orfriends)whoshareincome
andexpenses.Youmustincludeyourselfandallchildrenlivingwithyou.Ifyoulivewithother
peoplewhoareeconomicallyindependent(forexample,peoplewhoyoudonotsupport,whodonot
shareincomewithyouoryourchildren,andwhopayaproratedshareofexpenses),donotinclude
them.
14. WHATIFMYINCOMEISNOTALWAYSTHESAME?Listtheamountthatyounormallyreceive.For
example,ifyounormallymake$1000eachmonth,butyoumissedsomeworklastmonthandonly
made$900,putdownthatyoumake$1000permonth.Ifyounormallygetovertimepay,includeit,
butdonotincludeitifyouonlyworkovertimesometimes.Ifyouhavelostajoborhadyourhoursor
wagesreduced,useyourcurrentincome.
15. WEAREINTHEMILITARY.DOWEINCLUDEOURHOUSINGALLOWANCEASINCOME?Ifyouget
anoffbasehousingallowance,itmustbeincludedasincome.However,ifyourhousingispartofthe
MilitaryHousingPrivatizationInitiative,donotincludeyourhousingallowanceasincome.
16. MYSPOUSEISDEPLOYEDTOACOMBATZONE.ISHERCOMBATPAYCOUNTEDASINCOME?
No,ifthecombatpayisreceivedinadditiontoherbasicpaybecauseofherdeploymentanditwasnt
receivedbeforeshewasdeployed,combatpayisnotcountedasincome.Contactyourchildsschool
formoreinformation.
17. MYFAMILYNEEDSMOREHELP.ARETHEREOTHERPROGRAMSWEMIGHTAPPLYFOR?To
findouthowtoapplyforotherassistancebenefits,contactyourlocalassistanceoffice.

FreeandReducedPriceSchoolMealsApplication
LettertoHouseholds
Page2of2

INSTRUCTIONSFORAPPLYING
AHOUSEHOLDMEMBERISANYCHILDORADULTLIVINGWITHYOU.
IFYOURHOUSEHOLDRECEIVESBENEFITSFROMS U P P L E M E N T A L N U T R I T I O N A S S I S T A N C E P R O G R A M
(SNAP),TEMPORARYASSISTANCEFORNEEDYFAMILIES,ORTHEFOODDISTRIBUTIONPROGRAMONINDIAN
RESERVATIONS(FDPIR),FOLLOWTHESEINSTRUCTIONS:
Part1:Listallhouseholdmembersandthenameofschoolforeachchild.
Part2:Listthecasenumberforanyhouseholdmember(includingadults)receivingSNAP,TANForFDPIRbenefits.
Part3:Skipthispart.
Part4:Skipthispart.
Part5:Signtheform.ThelastfourdigitsofaSocialSecurityNumberarenotnecessary.
Part6:Answerthisquestionifyouchooseto.
IFNOONEINYOURHOUSEHOLDGETSSTATESUPPLEMENTALNUTRITIONASSISTANCEPROGRAM(SNAP),OR
TEMPORARYASSSISTANCEFORNEEDYFAMILIES(TANF)BENEFITSANDIFANYCHILDINYOURHOUSEHOLDIS
HOMELESS,AMIGRANTORRUNAWAY,FOLLOWTHESEINSTRUCTIONS:
Part1:Listallhouseholdmembersandthenameofschoolforeachchild.
Part2:Skipthispart.
Part3:Ifanychildyouareapplyingforishomeless,migrant,orarunawaychecktheappropriateboxandcallyourchilds
school.
Part4:CompleteonlyifachildinyourhouseholdisnteligibleunderPart3.SeeinstructionsforAllOtherHouseholds.
Part5:Signtheform.ThelastfourdigitsofaSocialSecurityNumberarenotnecessaryifyoudidntneedtofillinPart4.
Part6:Answerthisquestionifyouchooseto.
IFYOUAREAPPLYINGFORAFOSTERCHILD,FOLLOWTHESEINSTRUCTIONS:
Ifallchildreninthehouseholdarefosterchildren:
Part1:Listallfosterchildrenandtheschoolnameforeachchild.Checktheboxindicatingthechildisafosterchild.
Part2:Skipthispart.
Part3:Skipthispart.
Part4:Skipthispart.
Part5:Signtheform.ThelastfourdigitsofaSocialSecurityNumberarenotnecessary.
Part6:Answerthisquestionifyouchooseto.

Ifsomeofthechildreninthehouseholdarefosterchildren:
Part1:Listallhouseholdmembersandthenameofschoolforeachchild.Foranyperson,includingchildren,withnoincome,
youmustchecktheNoIncomebox.Checktheboxifthechildisafosterchild.
Part2:Ifthehouseholddoesnothaveacasenumber,skipthispart.
Part3:Ifanychildyouareapplyingforishomeless,migrant,orarunawaychecktheappropriateboxandcallyourchilds
school.Ifnot,skipthispart.

FreeandReducedPriceSchoolMealsApplication
InstructionforApplying
Page1of2

Part4:Followtheseinstructionstoreporttotalhouseholdincomefromthismonthorlastmonth.

Box1Name:Listallhouseholdmemberswithincome.

Box2GrossIncomeandHowOftenItWasReceived:Foreachhouseholdmember,listeachtypeofincome
receivedforthemonth.Youmusttellushowoftenthemoneyisreceivedweekly,everyotherweek,twiceamonth
ormonthly.Forearnings,besuretolistthegrossincome,notthetakehomepay.Grossincomeistheamount
earnedbeforetaxesandotherdeductions.Youshouldbeabletofinditonyourpaystuboryourbosscantellyou.

Forotherincome,listtheamounteachpersongotforthemonthfromwelfare,childsupport,alimony,pensions,
retirement,SocialSecurity,SupplementalSecurityIncome(SSI),Veteransbenefits(VAbenefits),anddisability
benefits.

UnderAllOtherIncome,listWorkersCompensation,unemploymentorstrikebenefits,regularcontributionsfrom
peoplewhodonotliveinyourhousehold,andanyotherincome.DonotincludeincomefromSNAP,FDPIR,WIC,
Federaleducationbenefitsandfosterpaymentsreceivedbythefamilyfromtheplacingagency.ForONLYtheself
employed,underEarningsfromWork,reportincomeafterexpenses.Thisisforyourbusiness,farm,orrental
property.IfyouareintheMilitaryPrivatizedHousingInitiativeorgetcombatpay,donotincludetheseallowancesas
income.
Part5:AdulthouseholdmembermustsigntheformandlistthelastfourdigitsoftheirSocialSecurityNumber(ormarkthebox
ifs/hedoesnthaveone).
Part6:Answerthisquestion,ifyouchoose.
ALLOTHERHOUSEHOLDS,INCLUDINGWICHOUSEHOLDS,FOLLOWTHESEINSTRUCTIONS:
Part1:Listallhouseholdmembersandthenameofschoolforeachchild.Foranyperson,includingchildren,withnoincome,
youmustchecktheNoIncomebox.
Part2:Ifthehouseholddoesnothaveacasenumber,skipthispart.
Part3:Ifanychildyouareapplyingforishomeless,migrant,orarunawaychecktheappropriateboxandcallyourchilds
school.Ifnot,skipthispart.
Part4:Followtheseinstructionstoreporttotalhouseholdincomefromthismonthorlastmonth.

Box1Name:Listallhouseholdmemberswithincome.

Box2GrossIncomeandHowOftenItWasReceived:Foreachhouseholdmember,listeachtypeofincome
receivedforthemonth.Youmusttellushowoftenthemoneyisreceivedweekly,everyotherweek,twiceamonth
ormonthly.Forearnings,besuretolistthegrossincome,notthetakehomepay.Grossincomeistheamount
earnedbeforetaxesandotherdeductions.Youshouldbeabletofinditonyourpaystuboryourbosscantellyou.

Forotherincome,listtheamounteachpersongotforthemonthfromwelfare,childsupport,alimony,pensions,
retirement,SocialSecurity,SupplementalSecurityIncome(SSI),Veteransbenefits(VAbenefits),anddisability
benefits.UnderAllOtherIncome,listWorkersCompensation,unemploymentorstrikebenefits,regular
contributionsfrompeoplewhodonotliveinyourhousehold,andanyotherincome.Donotincludeincomefrom
SNAP,FDPIR,WIC,Federaleducationbenefitsandfosterpaymentsreceivedbythefamilyfromtheplacingagency.
ForONLYtheselfemployed,underEarningsfromWork,reportincomeafterexpenses.Thisisforyourbusiness,farm,
orrentalproperty.DonotincludeincomefromSNAP,FDPIR,WICorFederaleducationbenefits.Ifyouareinthe
MilitaryPrivatizedHousingInitiativeorgetcombatpay,donotincludetheseallowancesasincome.
Part5:AdulthouseholdmembermustsigntheformandlistthelastfourdigitsoftheirSocialSecurityNumber(ormarkthebox
ifs/hedoesnthaveone).
Part6:Answer,thisquestionifyouchoose.

FreeandReducedPriceSchoolMealsApplication
InstructionforApplying
Page2of2

FREEANDREDUCEDPRICESCHOOLMEALSFAMILYAPPLICATION
PART1.ALLHOUSEHOLDMEMBERS
Namesofallhouseholdmembers
(First,MiddleInitial,Last)

Nameofschoolforeach
child/orindicateNAif
childisnotinschool

Checkifafosterchild(legalresponsibilityofwelfare
agencyorcourt)

CheckifNOincome

*Ifallchildrenlistedbelowarefosterchildren,skip
toPart5tosignthisform.

PART2.BENEFITS
IFANYMEMBEROFYOURHOUSEHOLDRECEIVES[SNAP],[FDPIR]OR[TANFCashAssistance],PROVIDETHENAMEANDCASE
NUMBERFORTHEPERSONWHORECEIVESBENEFITSANDSKIPTOPART5.IFNOONERECEIVESTHESEBENEFITS,SKIPTOPART3.
NAME:____________________________________________________________________CASENUMBER:_________________________________________________________ _
PART3.IFANYCHILDYOUAREAPPLYINGFORISHOMELESS,MIGRANT,ORARUNAWAYCHECKTHEAPPROPRIATEBOXANDCALL
YOURCHILDSSCHOOL.
HOMELESSMIGRANTRUNAWAY
PART4.TOTALHOUSEHOLDGROSSINCOME.Youmusttellushowmuchandhowoften.
1.NAME
(Listonlyhouseholdmemberswith
income)

2.GROSSINCOMEANDHOWOFTENITWASRECEIVED
EarningsFromWork
beforedeductions

Welfare,childsupport,
alimony

Pensions,retirement,
SocialSecurity,SSI,VA
benefits

AllOtherIncome

$199.99/weekly

$149.99/every other week $99.99/monthly

$50.00/monthly

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

$______/___________________

(Example)JaneSmith

FreeandReducedPriceSchoolMealsApplication
Application
Page1of3

PART 5. SIGNATURE AND LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (ADULT MUST SIGN)

An adult household member must sign the application. If Part 4 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 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 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: ___________________________________________________________________ Print name: _________________________________________________________________

Date: _________________________________________________________________________

Address: _____________________________________________________________________ Phone Number: _____________________________________________________________

City:__________________________________________________________________________ State: ____________________________ Zip Code:_______________________________

Last four digits of Social Security Number: * * * - * * - ___ ___ ___ ___ I do not have a Social Security Number
PART 6. CHILDRENS ETHNIC AND RACIAL IDENTITIES (OPTIONAL)
Choose one ethnicity:

Choose one or more (regardless of ethnicity):

Hispanic/Latino

Asian

Not Hispanic/Latino

White

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Black or African American

DO NOT 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: ______
Categorical Eligibility:

Eligibility: Free Reduced Denied

Determining Officials Signature: ________________________________________________ Date: ______________

Confirming Officials Signature: ________________________________ Date: ___________

Verifying Officials Signature: __________________________________ Date: ____________

Free and Reduced Price School Meals Application

Notice of Direct Certification
Page 1 of 1


Yourchildrenmayqualifyforfreeorreducedpricemealsifyourhouseholdincomefallsatorbelowthelimits
foundatthiswebsite:http://www.fns.usda.gov/cnd/governance/notices/iegs/RPieg.pdf

TheRichardB.RussellNationalSchoolLunchActrequirestheinformationonthisapplication.Youdonot
havetogivetheinformation,butifyoudonot,wecannotapproveyourchildforfreeorreducedpricemeals.
Youmustincludethelastfourdigitsofthesocialsecuritynumberoftheadulthouseholdmemberwhosigns
theapplication.Thelastfourdigitsofthesocialsecuritynumberisnotrequiredwhenyouapplyonbehalfof
afosterchildoryoulistaSupplementalNutritionAssistanceProgram(SNAP),TemporaryAssistancefor
NeedyFamilies(TANF)ProgramorFoodDistributionProgramonIndianReservations(FDPIR)casenumber
orotherFDPIRidentifierforyourchildorwhenyouindicatethattheadulthouseholdmembersigningthe
applicationdoesnothaveasocialsecuritynumber.Wewilluseyourinformationtodetermineifyourchildis
eligibleforfreeorreducedpricemeals,andforadministrationandenforcementofthelunchandbreakfast
programs.WeMAYshareyoureligibilityinformationwitheducation,health,andnutritionprogramstohelp
themevaluate,fund,ordeterminebenefitsfortheirprograms,auditorsforprogramreviews,andlaw
enforcementofficialstohelpthemlookintoviolationsofprogramrules.

NondiscriminationStatement:Thisexplainswhattodoifyoubelieveyouhavebeentreatedunfairly.In
accordancewithFederalLawandU.S.DepartmentofAgriculturepolicy,thisinstitutionisprohibitedfrom
discriminatingonthebasisofrace,color,nationalorigin,sex,age,ordisability.Tofileacomplaintof
discrimination,writeUSDA,Director,OfficeofAdjudication,1400IndependenceAvenue,SW,Washington,
D.C.202509410orcalltollfree(866)6329992(Voice).Individualswhoarehearingimpairedorhave
speechdisabilitiesmaycontactUSDAthroughtheFederalRelayServiceat(800)8778339;or(800)845
6136(Spanish).USDAisanequalopportunityproviderandemployer.

FreeandReducedPriceSchoolMealsApplication
Application
Page3of3

SHARINGINFORMATIONWITHMEDICAID/SCHIP

DearParent/Guardian:
Ifyourchildrengetfreeorreducedpriceschoolmeals,theymayalsobeabletogetfreeorlowcosthealth
insurancethroughMedicaidortheStateChildren'sHealthInsuranceProgram(SCHIP).Childrenwithhealth
insurancearemorelikelytogetregularhealthcareandarelesslikelytomissschoolbecauseofsickness.
Becausehealthinsuranceissoimportanttochildrenswellbeing,thelawallowsustotellMedicaidandSCHIP
thatyourchildrenareeligibleforfreeorreducedpricemeals,unlessyoutellusnotto.MedicaidandSCHIP
onlyusetheinformationtoidentifychildrenwhomaybeeligiblefortheirprograms.Programofficialsmay
contactyoutooffertoenrollyourchildren.FillingouttheFreeandReducedPriceSchoolMealsApplication
doesnotautomaticallyenrollyourchildreninhealthinsurance.
IfyoudonotwantustoshareyourinformationwithMedicaidorSCHIP,fillouttheformbelowandsendin
(Sendinginthisformwillnotchangewhetheryourchildrengetfreeorreducedpricemeals).

No!IDONOTwantinformationfrommyFreeandReducedPriceSchoolMealsApplicationshared
withMedicaidortheStateChildren'sHealthInsuranceProgram.

Ifyoucheckedno,fillouttheformbelowtoensurethatyourinformationisNOTsharedforthechild(ren)
listedbelow:
Child'sName:___________________________________________School:_______________________________________________________
Child'sName:___________________________________________School:_______________________________________________________
Child'sName:___________________________________________School:_______________________________________________________
Child'sName:___________________________________________School:_______________________________________________________
SignatureofParent/Guardian:________________________________________________________Date: ________________________
PrintedName:__________________________________________________________________________________________________________
Address:________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Formoreinformation,callyourchildsschool.

FreeandReducedPriceSchoolMealsApplication
NoticeofDirectCertification
Page1of1
SY20122013