Pennsylvania Household Application For Free & Reduced Price School Meals And Special Milk Program - 2016-2017 Page 2

INSTRUCTIONS

Sources of Income

Sources of Income for Children

Sources of Income for Adults

Pensions / Retirement /

Public Assistance /

Sources of Child Income

Earnings from Work

Example(s)

Alimony / Child Support

All Other Income

- A child has a regular full or part-time job

-

- Salary, wages, cash

Unemployment benefits

- Earnings from work

-

Social Security

where they earn a salary or wages

-

Worker’s compensation

(including railroad

bonuses

- Net income from self-

-

retirement and black lung

Supplemental Security

- A child is blind or disabled and receives Social

- Social Security

benefits)

employment (farm or

Income (SSI)

- Disability Payments

Security benefits

-

Private pensions or

business)

-

Cash assistance from

- Survivor’s Benefits

- A Parent is disabled, retired, or deceased, and

disability benefits

State or local

their child receives Social Security benefits

-

Regular income from

government

If you are in the U.S. Military:

trusts or estates

-Income from person outside the household

- A friend or extended family member

-

Alimony payments

-

Annuities

regularly gives a child spending money

-

- Basic pay and cash bonuses

Child support payments

-

Investment income

Veteran’s benefits

-

(do NOT include combat pay,

-

Earned interest

Strike benefits

-

FSSA or privatized housing

-

-Income from any other source

- A child receives regular income from a

Rental income

allowances)

private pension fund, annuity, or trust

-

Regular cash payments

- Allowances for off-base

from outside household

housing, food and clothing

OPTIONAL

Children's Racial and Ethnic Identities

We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community.

Responding to this section is optional and does not affect your children’s eligibility for free or reduced price meals.

Hispanic or Latino

Not Hispanic or Latino

Ethnicity (check one):

Native Hawaiian or Other Pacific Islander

American Indian or Alaskan Native

Asian

Black or African American

White

Race (check one or more):

Persons with disabilities who require alternative means of communication for program information (e.g. Braille,

The Richard B. Russell National School Lunch Act requires the information on this application. You do

large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they

not have to give the information, but if you do not, we cannot approve your child for free or reduced price

applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA

meals. You must include the last four digits of the social security number of the adult household member who

through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made

signs the application. The last four digits of the social security number is not required when you apply on

available in languages other than English.

behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form,

Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations

(FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household

(AD-3027) found online at: , and at any USDA office, or

member signing the application does not have a social security number. We will use your information to

write a letter addressed to USDA and provide in the letter all of the information requested in the form. To

determine if your child is eligible for free or reduced price meals, and for administration and enforcement of

request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

the lunch and breakfast programs. We MAY share your eligibility information with education, health, and

U.S. Department of Agriculture

mail:

nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for

Office of the Assistant Secretary for Civil

program reviews, and law enforcement officials to help them look into violations of program rules.

Rights 1400 Independence Avenue, SW

Washington, D.C. 20250-9410

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations

and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or

fax:

(202) 690-7442; or

administering USDA programs are prohibited from discriminating based on race, color, national origin, sex,

email:

program.intake@usda.gov.

disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or

This institution is an equal opportunity provider.

funded by USDA.

Do not fill out

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, ☐ Monthly, ☐Yearly,

Household Size:___________ Date Withdrawn:__________

Determining Official’s Signature: ___________________________________________ Date:____________

Eligibility: ☐ Free

☐ Reduced

☐ Denied Reason:______________________________________

☐ Categorically Eligible

☐Other Source Categorically Eligible

Confirming Official’s Signature (cannot be the Determining Official):_____________________________________________Date:_________________ Signature of School Employee Completing Verification: ____________________________________________Date:_________________