Application For Free And Reduced Price School Meals/milk

Date Withdrew__________

F ____R _____D_____

2017-2018 Application for Free and Reduced Price School Meals/Milk

To apply for free and reduced price meals for your children, read the instructions on the back, complete only one form for your

household, sign your name and return it to the address listed below. Call (phone number), if you need help. Additional names

may be listed on a separate paper.

Return Completed Applications to:

(School Name)

(Street Name)

(City, State , Zip Code)

1. List all children in your household who attend school:

Homeless

Student Name

School

Grade/Teacher

Foster Child

Migrant,

Runaway

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2. SNAP/TANF/FDPIR Benefits:

If anyone in your household receives either SNAP, TANF or FDPIR benefits, list their name and CASE # here. Skip to Part 4, and sign the application.

Name: ______________________________________ CASE #: __________________________________

3. Report all income for ALL Household Members (Skip this step if you answered ‘yes’ to step 2)

All Household Members (including yourself and all children that have income).

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 income for each source in whole dollars only. If they do not receive income from any other source, write ‘0’. If you enter ‘0’ or leave any fields

blank, you are certifying (promising) that there is no income to report.

Name of household member

Earnings from work

Child Support, Alimony

Pensions, Retirement

Other Income, Social

before deductions

Payments

Security

Income

Amount / How Often



$ ________ / ________



$ ________ / ________



$ ________ / ________



$ ________ / ________

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$ ________ / ________

I do not

Total Household Members (Children and Adults)

have a

*Last Four Digits of Social Security Number: XXX-XX- __ __ __ __



SS#

*When completing section 3, an adult household member must provide the last four digits of their Social Security Number (SS#), or mark the “I do not have a SS#

box” before the application can be approved.

4. Signature: An adult household member must sign this application before it can be approved.

I certify (promise) that all the information on this application is true and that all income is reported. I understand that the information is being given so the school

will get federal funds; the school officials may verify the information and if I purposely give false information, I may be prosecuted under applicable State and

federal laws, and my children may lose meal benefits.

Signature: ___________________________________________________ Date: ___________________

Email Address: ________________________________________________

Home Phone: _____________________ Work Phone: _________________________ Home Address:____________________________________________

5. Ethnicity and Race are optional; responding to this section does not affect your children’s eligibility for free or reduced price meals.



Ethnicity:

Hispanic or Latino

Not Hispanic or Latino



Native Hawaiian or Other Paciﬁc Island

Race: