Date Received: _____________
APPLICATION FOR FREE AND REDUCED-PRICE SCHOOL MEALS
PART 1. ALL HOUSEHOLD MEMBERS
Check If a Foster
Child (Legal
Names of ALL Household
Name of School for Each
Grade
Birth Date
Check if
Responsibility of
Members
Child/Or Indicate NA If
NO
Welfare Agency or
(First, Middle Initial, Last)
Court)*
Person Is Not in School
Income
(Must be
*If all children in the
checked
household are foster
if no
children, skip to Part
5 to sign this form.
income)
PART 2. BENEFITS
If any member of your household receives SNAP, TANF, or FDPIR, provide the name and case number for the
ONE person who receives benefits and skip to Part 5. If no one receives these benefits, skip to Part 3.
NAME:
CASE NUMBER:
PART 3. IF ANY CHILD YOU ARE APPLYING FOR IS HOMELESS, MIGRANT, OR A RUNAWAY,
CHECK THE APPROPRIATE BOX AND CALL (YOUR SCHOOL, HOMELESS LIAISON, OR MIGRANT
COORDINATOR) AT PHONE NUMBER ______________________________.
Homeless
Migrant
Runaway
NOTE TO SFA: A household completing this part does not automatically qualify the child for eligibility. The child must be
on the Homeless, Migrant, Runaway List to qualify for free meal benefits.
PART 4. TOTAL HOUSEHOLD GROSS INCOME. You must tell us how much and how often.
A. NAME
B. GROSS INCOME AND HOW OFTEN IT WAS RECEIVED
(List only household
Earnings From Work
Pensions, Retirement,
All Other Income
members with income)
Welfare, Child Support,
Before Deductions
Social Security, SSI, VA
Alimony
Benefits
149.99
every other
50.00
monthly
99.99
monthly
$________/________
199.99
weekly
$________/________
$________/________
$________/________
(Example) Jane Smith
week
$________/________
$________/________
$________/________
$________/________
$________/________
$________/________
$________/________
$________/________
$________/________
$________/________
$________/________
$________/________
$________/________
$________/________
$________/________
$________/________
$________/________
$________/________
$________/________
$________/________
Oklahoma State Department of Education Eligibility Documentation, July 2012
E-61