PART 5. SIGNATURE AND LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (ADULT MUST
SIGN)
An adult household member must sign the application. If Part 4 is completed, the adult signing the form also
must list the last four digits of his or her social security number or mark the I do not have a social security
number box. (See Privacy Act Statement on the back of the next page.)
I certify (promise) that all information on this application is true and that all income is reported. I understand that
the school will get federal funds based on the information that I give. I understand that school officials may verify
(check) the information. I understand that if I purposely give false information, my children may lose meal
benefits and I may be prosecuted.
Sign Here:
Date:
Print Name:
Address:
Phone Number:
City:
State:
Zip Code:
Last four digits of social security number: *** - **-
I do not have a social security number.
Part 6: Children’s Ethnic and Racial Identities (Optional)
Choose one or more (regardless of ethnicity):
Choose one ethnicity:
Hispanic or Latino
Asian
American Indian or Alaska Native
Black or African American
White
Native Hawaiian or other Pacific Islander
Not Hispanic or Latino
PART 7: OTHER BENEFITS: You do not have to complete this part to get free or reduced-price school meals.
Health Insurance
Yes, I want health insurance for my children. School officials may give information from
my Application for Free and Reduced-Price School Meals to Medicaid or Sooner Care
Benefits officials so that they can send me information about free or low-cost health
insurance for my children.
No, I DO NOT want information from my Application for Free and Reduced-Price School
Meals shared with Medicaid or Sooner Care Benefits officials.
I certify that I am the parent/guardian of the children for whom application is being made.
I understand that I will be releasing information that will show that I applied for free or reduced-price school meals for
my children. I give up my rights to confidentiality for this purpose only.
Signature of Parent/Guardian:
Date:
E-62
Oklahoma State Department of Education Eligibility Documentation, July 2012