Free & Reduced Price School Meals Family Application Form printable pdf download

– complete one application per household

Free & Reduced Price School Meals Family Application

Attachment C: 2014-15

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

Grade



Part 2: 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 Names

2. Gross Income and How Often it was Received

List everyone in household and the

Check

Pensions, Retirement,

income each earns & how often OR

if NO

Earnings from Work

Welfare, Child

Social Security, SSI,

All Other Income

check the box at the right if they have

income

before deductions

Support, Alimony

VA Benefits, Disability

(Self Employment)

no income. A foster child’s personal

Income

How often

Income How often

Income

How often

Income

How often

use income must be listed.



Part 4: Signature and Social Security Number (Adult Must Sign)

An adult household member must sign the application. If Part 3 is completed, the adult signing the form must list the last four digits of their

Social Security Number or mark the “I do not have a Social Security Number” box. (See Use of Information Statement on page 2)

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:___________________________________________________Zip___________ Phone Number:______________________



Social Security Number (last 4 digits): XXX – XX – __ __ __ __

I do not have a Social Security Number

Part 5: Children’s Ethnic and Racial Identities (Optional)

Mark one Ethnic Identity: - - and - -

Mark one or more Racial Identities:



Hispanic or Latino

Asian

Black or African American

Native Hawaiian or



Not Hispanic or Latino

White

American Indian or Alaska Native

other Pacific Islander

Do Not Fill Out This Part. 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_________

Free

Total Income $ ______________ per



Reduced

Date Withdrawn

 Year  Month  2 X Mo.  Every 2 Wks  Week

from School

: _______________________



Categorically Eligible: SNAP/TANF/FDPIR 

Denied

Reason for Denial:

Foster Child 

Income too high  Incomplete App. 

Signature of Determining Official ___________________________________________________________ Date Approved: ________________________

Signature of Confirming Official (Verification only) _____________________________________________ Date Confirmed:________________________

NE Department of Education – Nutrition Services

Page 1 of 2

National School Lunch Program

Free & Reduced Price School Meals Family Application Form

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