Free And Reduced Price School Meals Family Application - Nebraska Department Of Education

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Free & Reduced Price School Meals Family Application
– complete one application per household
Attachment C: 2016-17
Part 1: Children in School
List names of all children, including foster children, in school.
Check box
If all children listed are foster, skip to Part 4 to sign the form.
below if a
(First, Middle Initial, Last Name)
foster child
Name of School Child Attends
Part 2: Assistance Programs – SNAP, TANF or FDPIR Benefits
Enter MASTER CASE NUMBER if household qualifies for SNAP, TANF or FDPIR:
(Social Security numbers, Medicaid numbers and EBT numbers are not accepted.) Skip to Part 4
Part 3: Total Household Gross Income –
You must tell us how much and how often.
1. Household Members
2. Gross Income (before taxes) and How Often it was Received
List everyone in the household, current income each
Earnings from Work
Public Assistance, Child
Pensions, Retirement and
person earns in whole dollars (no cents) & how often.
before deductions
Support, Alimony
All Other Income
Entering “0” or leaving the income field blank certifies
no income to report. A foster child’s personal use
How often
How often
How often
income must be listed.
Last four digits of Social Security Number (SSN) of the
Total Number of Household Members:
Check if no SSN
XXX – XXX – __ __ __ __
(Children and Adults)
adult signing this form:
Part 4: Adult Signature and Contact Information –
An adult household member must sign the application.
“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.”
Sign here:
Print name:
Street Address
Daytime Phone:
(if available):
Part 5: Children’s Ethnic and Racial Identities –
– and –
Check one Ethnic Identity:
Check one or more Racial Identities:
Hispanic or Latino
Black or African American
Native Hawaiian or
other Pacific Islander
Not Hispanic or Latino
American Indian or Alaskan Native
Do Not Fill Out the Section Below - For School Use Only
Annual Income Conversion:
Weekly X 52;
Every 2 weeks X 26;
Twice a month X 24;
Monthly X 12
Total Household Size:_______________________
Reason for denial:
Income too high
Categorically eligible:
Total Income:______________________________
Incomplete application
2 X Mo
Every 2 Wks
Foster Child
Signature of Determining Official:
Date Approved:
Date Withdrawn
From School:
Signature of Confirming Official:
Date Confirmed:
Signature of Verifying Official:
Date Verified:
NE Department of Education – Nutrition Services
National School Lunch Program
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