Pennsylvania Household Application For Free & Reduced Price School Meals And Special Milk Program - 2016-2017

2016-2017 Pennsylvania Household Application for Free & Reduced Price School Meals and Special Milk Program

(

Complete one application per household. Please use a pen)

STEP 1

List ALL Household Members who are infants, children, and students up to and including grade 12 (if more spaces are required for additional names, attach another sheet of paper)

Homeless,

Grade

Student?

Child’s First Name

Child’s Last Name

Foster

Migrant,

MI

Enter HS for Head Start

Definition of Household

Yes

No

Child

Runaway

Member: “Anyone who is

living with you and shares

income and expenses, even

if not related.”

Children in Foster care and

children who meet the

definition of Homeless,

Migrant or Runaway are

eligible for free meals. Read

How to Apply for Free and

Reduced Price School

Meals for more information.

STEP 2

Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP or TANF

Case Number:

> Go to STEP 3.

If NO

If YES >

Write a case number here then go to STEP 4 (Do not complete STEP 3)

Write only one case number in this space.

STEP 3

Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2)

How often?

A. Child Income

Weekly

Bi-Weekly 2x Month

Monthly

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 (including yourself)

Are you unsure what

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.

income to include here?

How often?

How often?

How often?

Flip the page and review

Public Assistance/

Pensions/Retirement/

the charts titled “Sources

Earnings from Work

Weekly

Bi-Weekly 2x Month Monthly

Child Support/Alimony

Weekly Bi-Weekly

2x Month Monthly

All Other Income

Weekly

Bi-Weekly 2x Month

Monthly

Name of Adult Household Members (First and Last)

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.

Last Four Digits of Social Security Number (SSN) of

Total Household Members

X

X

X X

X

Check if no SSN

Primary Wage Earner or Other Adult Household Member

(Children and Adults)

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.”

Street Address (if available)

City

State

Zip

Daytime Phone and Email (optional)

Apt #

Today’s date

Printed name of adult signing the form

Signature of adult