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Write a “0” in any fields where there is no income to report. Any income fields left empty or blank will also be counted as a zero. If you write ‘0’ or leave any fields blank, you are

certifying (promising) that there is no income to report. If local officials suspect that your household income was reported incorrectly, your application will be investigated.

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Mark how often each type of income is received using the check boxes to the right of each field.

3.A. REPORT INCOME EARNED BY CHILDREN

A) Report all income earned or received by children. Report the combined gross income for ALL children listed in STEP 1 in your household in the box marked “Child Income.” Only

count foster children’s income if you are applying for them together with the rest of your household.

What is Child Income? Child income is money received from outside your household that is paid DIRECTLY to your children. Many households do not have any child income.

3.B REPORT INCOME EARNED BY ADULTS

Who should I list here?

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When filling out this section, please include ALL adult members in your household who are living with you and share income and expenses, even if they are not related and even

if they do not receive income of their own.

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Do NOT include:

People who live with you but are not supported by your household’s income AND do not contribute income to your household.

Infants, Children and students already listed in STEP 1.

B) List adult household members’

C) Report earnings from work. Report all income from work in the

D) Report income from public assistance/child

names. Print the name of each

“Earnings from Work” field on the application. This is usually the

support/alimony. Report all income that applies in the “Public

household member in the boxes marked

money received from working at jobs. If you are a self-employed

Assistance/Child Support/Alimony” field on the application. Do

“Names of Adult Household Members

business or farm owner, you will report your net income.

not report the cash value of any public assistance benefits NOT

(First and Last).” Do not list any

listed on the chart. If income is received from child support or

household members you listed in STEP 1.

alimony, only report court-ordered payments. Informal but

What if I am self-employed? Report income from that work as a net

If a child listed in STEP 1 has income,

regular payments should be reported as “other” income in the

amount. This is calculated by subtracting the total operating

follow the instructions in STEP 3, part A.

next part.

expenses of your business from its gross receipts or revenue.

E) Report income from

F) Report total household members. Enter the total number of

G) Provide the last four digits of your Social Security Number.

pensions/retirement/all other income.

household members in the field “Total Household Members

An adult household member must enter the last four digits of

Report all income that applies in the

(Children and Adults).” This number MUST be equal to the number

their Social Security Number in the space provided. You are

“Pensions/Retirement/ All Other

of household members listed in STEP 1 and STEP 3. If there are any

eligible to apply for benefits even if you do not have a Social

Income” field on the application.

members of your household that you have not listed on the

Security Number. If no adult household members have a Social

application, go back and add them. It is very important to list all

Security Number, leave this space blank and mark the box to the

household members, as the size of your household affects your

right labeled “Check if no SSN.”

eligibility for free and reduced price meals.

STEP 4: CONTACT INFORMATION AND ADULT SIGNATURE

All applications must be signed by an adult member of the household. By signing the application, that household member is promising that all information has been truthfully

and completely reported. Before completing this section, please also make sure you have read the privacy and civil rights statements on the back of the application.

A) Provide your contact information. Write your current

B) Print and sign your name. Print

C) Write today’s date.

D) Share children’s racial and ethnic identities

address in the fields provided if this information is available.

the name of the adult signing the

In the space provided,

(optional). On the back of the application, we ask you

If you have no permanent address, this does not make your

application and that person signs

write today’s date in

to share information about your children’s race and