Jefferson School District 2009 — 2010 School Site __

Martin Luther King Jr. Education Center

101 Lincoln Avenue, Daly City, CA 94015 APPLICATION FOR FREE & REDUCED PRICE MEALS
Tel 650.746-2516 • Fax 650.991-1298
SECTION A: All households complete this section and return application to school EXCEPT those that received a Blue 2009-2010 Direct
Certification Letter, unless you do not want to apply.
ALL STUDENT / CHILD INFORMATION FOOD STAMP (FS), FOR
(ONE DAY OLD THROUGH 20 YRS OLD) CALWORKS, KINGAP OR FOSTER CHILD SCHOOL
FDPIR BENEFITS USE ONLY
CURRENT R G If YES, complete one
WRITE
CHILDREN’S CHILDREN’S SCHOOL WRITE If YES, enter case application per Foster
O R
YES
YES STUDENT
INITIALS number below for each Child. Enter child’s
LAST NAMES FIRST NAMES Write N/A O A Or
OR
ID
NO
child NO monthly personal-use
if not in M D
school income
# E
1. $
2.
3.
4.
5.
If you entered a Food Stamp, CalWORKS, KinGAP or FDPIR case number for each child in Section A, or if this application is for a Foster Child and you
entered his/her monthly personal-use income, skip Section B and complete Section C
SECTION B: HOUSEHOLD MEMBERS(see back for definition) and THEIR MONTHLY INCOME (IF ANY)
(1) List all adult household members, whether or not they have income; (2) Indicate amount(s) and source(s) of income for those adult household
members with income last month; (3) Enter any income received last month by/for a child from full-time or regular part-time employment, SSI or
Adoption Assistance payments; and (4) If amount last month was more/less than usual, enter the usual amount. (5) If no income write “0” (zero).
MONTHLY Pension, Welfare benefits,
ALL ADULTS FULL NAMES Gross earnings retirement, social child support, Any other FOR SCHOOL USE
from work before security income alimony monthly income ONLY
deductions; payments TOTAL MONTHLY
include all jobs INCOME
1. $ $ $ $
2. $ $ $ $
3. $ $ $ $
4. $ $ $ $
5. $ $ $ $
California Education Code Section 49557(a): Applications for free and reduced-price meals may be submitted at any time during a school day. Children
participating in the National School Lunch Program will not be overtly identified by the use of special tokens, special tickets, special serving lines, separate
entrances, separate dining areas or any other means.
Privacy Act Statement: National School Lunch Act (Section 9) requires that, unless your child’s Food Stamp, CalWORKS, KinGAP or FDPIR case number is provided,
you must include the social security number of the adult household member signing the application or indicate that the household member signing the application does not
have a social security number. Provision of a social security number is not mandatory, but if a social security number is not given or an indication is not made that the
signer does not have such a number, the application cannot be approved. The social security number may be used to identify the household member in carrying out efforts
to verify the correctness of the information stated on the application. These verification efforts may be carried out through program reviews, audits, and investigations and
may include contacting employers to determine income, contacting the State’s Employment Development Department offices, or local welfare offices to determine the
amount of benefits received and checking the documentation produced by household members to prove the amount of income received. Reporting incorrect information
may result in loss or reduction of the household’s program benefits, or in administrative claims and/or legal actions against household members.
SECTION C: ALL HOUSEHOLDS READ and COMPLETE THIS SECTION
I certify that all of the above information is true and correct and that all income is reported. I understand that this information is given for the receipt of
Federal funds, that school officials may verify the information on the application at any time, and that deliberate misrepresentation of the information
may subject me to prosecution under applicable State and Federal laws.
Signature of adult household member completing this form: Telephone Number: Date:
( )
Printed name of adult household member signing this application: Social Security Number (write “none” if N/A):

Address:

City: State: Zip Code: Total # of adults and children in household:

SECTION D: CHILDREN’S RACIAL and ETHNIC IDENTITIES (optional) This institution is an Equal Opportunity Provider and Employer
American Indian or Black or Native Hawaiian or
1. Mark one or more racial identities: Alaska Native Asian African-American Pacific Islander White

2. Mark one ethnic identity: Of Hispanic or Latino origin Not of Hispanic or Latino origin
FOR SCHOOL USE ONLY — ELIGIBILITY DETERMINATION 8/13/2009 Direct Certified as: H M R _____ EP
FREE REDUCED DENIED CATEGORICALLY FREE WITH FOOD STAMP, CALWORKS, KINGAP OR FDPIR BENEFITS
ZERO INCOME, TEMPORARY FREE UNTIL (UP TO 45 CALENDAR DAYS FROM DATE OF THIS DETERMINATION):
ND
2 REVIEW: VERIFICATION OFFICIAL: DATE: FOLLOW-UP:
HOUSEHOLD SIZE: HOUSEHOLD INCOME: DETERMINING OFFICIAL: DATE:
 Jefferson School District
101 LINCOLN AVENUE  DALY CITY  CA  94015
Dear Parent/Guardian:
The JEFFERSON SCHOOL DISTRICT serves lunch every school day. Students may buy lunch for $2.75. Students may be eligible for free meals if they reside in households receiving food
stamps, KinGAP, FDPIR, or CalWORKS. They also may receive meals free of charge or at a reduced price of $ .40 if their household incomes are within the levels shown on the scale
below. To apply for free or reduced price meals, please complete the application on the reverse side and return it to the school as soon as possible. New applications must be submitted
each school year, except for those notified by mail of Direct Certification. Instructions for completing the application follow. The application cannot be approved unless it contains
complete eligibility information.
FOR FOOD STAMP, CALIFORNIA WORK OPPORTUNITY AND RESPONSIBILITY TO KIDS (CALWORKS), KINSHIP GUARDIANSHIP ASSISTANCE PAYMENTS (KINGAP) OR FOOD
DISTRIBUTION PROGRAM INDIAN RESERVATIONS (FDPIR) HOUSEHOLDS:
If you now receive Food Stamp, CalWORKS, KinGAP, or FDPIR benefits for your child(ren), you should have received a yellow notification of Direct Certification and you DO NOT
submit a new application. If you did not receive a notification of eligibility through Direct Certification for your child(ren), list each child’s name, and your Food Stamp, CalWORKS,
KinGAP, or FDPIR case number. New students are not directly certified and some continuing students may have been inadvertently missed in the matching process. New applications
must be filled out for those students. If a Food Stamp, CalWORKS, KinGAP, or FDPIR case number for the child is listed, or if the application is for a foster child, a social security
number is not needed. An adult household member must sign the application.
WIC PARTICIPANTS: If you currently receive benefits under the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC Program), your child may be eligible for
free or reduced-price meals. You are encouraged to complete an application and return it to the school for processing.

FOSTER OR INSTITUTIONALIZED CHILDREN:

Use one application per foster or institutionalized child who is the legal responsibility of the welfare agency or the court. Write the name of the child and the specific school he/she attends.
If the child receives “personal use income”, list the amount of income. “Personal use income” is (a) money given by the welfare office identified by category for the child’s personal use,
such as clothing, school fees and allowances; and (b) all other money the child gets, such as money from family and money from the child’s full-time or regular part-time jobs. A social
security number is not needed. If a child is living with relatives or friends and is not a ward of the court or the welfare agency, the application must be completed with all household
members and income listed. . In some cases Foster children are eligible for free or reduced-price meals regardless of the household’s income. The foster parent or agency
official must sign the application.
ALL OTHER INCOME HOUSEHOLDS (wages, salary, pensions, etc.): For each student listed on the application, you must enter: the names of all the children and the schools they attend,
the names of other children who do not attend any school, the names of all the adults (21 years and older) and other household members, the amount each person received last month, and
the source of income. HOUSEHOLD means a group of related, or non-related, individuals who are living as one economic unit and sharing living expenses. Living expenses include rent,
clothes, food, doctor bills, and utility bills. An adult household member must sign the application and enter their social security number. Indicate “none” if the adult does not have a social
security number. An application must be completed, with all household members and income listed, for a child who is living with relatives or friends, whether or not the child is a ward of
the court. Incomplete applications may be returned.

CURRENT INCOME: The amount of income each household member received last month, before taxes or anything else that is taken out, and where it came from, such as earnings, welfare,
pensions, and other income. If any amount last month was more or less than usual, write the usual monthly income or project the annual income. To figure monthly income: Annual
Income divided by 12; Twice per Month=annual income divided by 24; Every 2 weeks =annual income divided by 26; and Weekly=annual income divided by 52.

VERIFICATION: The information on the application may be checked by school officials at any time during the school year. Proof may be required.

MEALS FOR THE DISABLED: A child with a disability is entitled to a special meal, at no extra charge, if the disability prevents the child from eating the regular school meal.
APPLYING FOR FREE & REDUCED MEALS: You may submit an application at any time during the school year. If you are not eligible now, but your income decreases, or if you are no
longer employed or your family size changes, or you become eligible for Food Stamp, CalWORKS, KinGAP, or FDPIR benefits you may complete an application at that time.

NONDISCRIMINATION: 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 Civil Rights, Room 326-W, Whitten Bldg., 1400 Independence Avenue, SW,
Washington, D.C. 20250-9410 or call (202) 720-5964 (voice & TDD). USDA is an equal opportunity provider and employer. Persons with disabilities who require alternative means for
communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s Target Center at (202) 720-2600 (voice & TDD).

FAIR HEARING: If you do not agree with the decision on your application or the result of verification, you may wish to discuss it with the Food Service Department. You also have the
right to a fair hearing. This can be done by calling or writing the following school official: JEFF DAVIES, JEFFERSON SCHOOL DISTRICT, 101 Lincoln Avenue, Daly City, CA 94015 - Phone
(650) 746-2411.

CONFIDENTIALITY: The information you give on the application will not be given to anyone who is not part of the Jefferson Elementary School District food program. The information
will be used only to determine if your children are eligible for free or reduced price meals. If you have any questions, please contact FOOD SERVICES at (650) 746-2516. You will be
notified whether your application is approved or denied by our office.

Sincerely yours,

Enrique Navas
Assistant Superintendent, Business Services

INCOME ELIGIBILITY GUIDELINES: JULY 1, 2009 THROUGH JUNE 30, 2010

HOUSEHOLD SIZE YEAR MONTHLY TWICE PER EVERY TWO WEEKLY
MONTH WEEKS

1* $ 20,036 $ 1,670 $ 835 $ 771 $ 386

2 $ 26,955 $ 2,247 $ 1,124 $ 1,037 $ 519
3 $ 33,874 $ 2,823 $ 1,412 $ 1,303 $ 652
4 $ 40,793 $ 3,400 $ 1,700 $ 1,569 $ 785
5 $ 47,712 $ 3,976 $ 1,988 $ 1,836 $ 918
6 $ 54,631 $ 4,553 $ 2,277 $ 2,102 $ 1,051
7 $ 61,550 $ 5,130 $ 2,565 $ 2,368 $ 1,184
8 $ 68,469 $ 5,706 $ 2,853 $ 2,634 $ 1,317
For each additional household member add:
+ $ 6,919 $ 577 $ 289 $ 267 $ 134
* A household of one means a foster child, a child in out-of-home care, or a pupil who is his/her sole support.