Application For Free And Reduced Price School Meals - 2017-2018

2017 - 2018 Application for Free and Reduced Price School Meals - VT Agency of Education

App #

Complete one application per household. Please use a pen (not a pencil).

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

Student?

Foster

Migrant

Definition of Household

Member: “Anyone who is

Child’s First Name

MI

Child’s Last Name

School Name

Grade

Yes

No

Child

Runaway

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: 3SquaresVT or Reach-Up?

Case Number: __ __ __ - __ __ - __ __ __ __

If NO > Complete STEP 3. If YES > Write a case number here then go to STEP 4 (Do not complete STEP 3)

STEP 3

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

A.

Child Income

Sometimes children in the household earn income. Please include the TOTAL income earned by all Children listed in STEP 1 here, if

Child Income

2x

applicable. See back for more information.

Weekly Bi-Weekly

Monthly

Month

Please read How to

All Adult Household Members (including yourself)

B.

List all Household Members not listed in STEP 1 (including yourself) even if

Apply for Free and

$

they do not receive income. For each Household Member listed, if they do receive income, report total for source in whole dollars only. If they do

Reduced Price School

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.

Meals for more

information. The

Public Assistance/

Pensions/Retirement/

Bi-

2x

Bi-

2x

Bi-

2x

Sources of Income for

Child Support/

All Other Income

Weekly

Monthly

Weekly

Monthly

Weekly

Monthly

Weekly

Month

Weekly

Month

Weekly

Month

Children section will

Name Adult Household Members (First & Last)

Earnings from Work

Alimony

help you with the

$

$

$

Child Income

question. The Sources

$

$

$

of Income for Adults

section will help you

$

$

$

with the All Adult

$

$

$

Household Members

section.

Total Household Members

Last Four Digits of Social Security Number (SSN) of Primary Wager Earner

Check if no

X X

☐

X X X

(Children and Adults)

or Other Adult Household Member

SSN

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.”

Signature of adult completing the form

Printed name of adult completing the form

Today’s date

Cell Phone Number

Street Address (if available)

Apt #

City

State

Zip

Email (optional)

Other Benefits: For information on free or low-cost health insurance contact Green Mountain Care at 1-800-250-8427 or For information on 3SquaresVT to help with food costs, call 1-800-479-6151 or visit

Do Not Fill Out

For School Use Only

Eligibility

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly x 12

Total Income

Household Size

Free

Reduced

Denied

Frequency

Categorical Eligibility

Weekly

Bi-Weekly

2x Month

Monthly

Yearly

Determining Official’s Signature

Date

Confirming Official’s Signature

Date

Verifying Official’s Signature

Date