Application Form For Free And Reduced-Price School Meals - Oklahoma State Department Of Education Eligibility Documentation Page 3
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4DO NOT FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY.
Annual Income Conversion: Weekly x 52,
Every 2 Weeks x 26,
Twice a Month x 24,
Monthly x 12
Income Eligibility:
Total Income: ________ Per: Week ____ Every 2 Weeks ____ Twice a Month _____ Month _____ Year ____
Household Size: __________
Eligibility: Free
Reduced
Denied
Categorical Eligibility:
SNAP/TANF
FDPIR
Other Source Categorical Eligibility:
Other Source Categorical Eligibility:
Head Start
Even Start
Homeless
Migrant
Runaway
Head Start
Even Start
Homeless
Migrant
Runaway
Foster Child
Reason:
Date Withdrawn:
Determining Official’s Signature:
Date:
Confirming Official’s Signature:
Date:
(For Confirmation Reviews Under Verification)
Verifying Official’s Signature:
Date:
(If stamped signature is used, signature must be registered with the Secretary of State and the SFA must have this on
file.)
185% of Poverty Level
2013
FEDERAL ELIGIBILITY INCOME CHART for School Year ______
Household Size
Yearly
Monthly
Weekly
Your children may
1
20,665
1,723
398
qualify for free or re-
2
27,991
2,333
539
duced-price meals if
3
35,317
2,944
680
your household in-
4
42,643
3,554
821
come falls at or below
5
49,969
4,165
961
the limits of this chart.
6
57,295
4,775
1,102
7
64,621
5,386
1,243
8
71,947
5,996
1,384
Each additional person:
7,326
611
141
Privacy Act Statement: This explains how we will use the information you give us.
The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you
do not, we cannot approve your child for free or reduced-price meals. You must include the last four digits of the social security number of the adult
household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster
child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), or Food Distribution
Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household
member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free
or reduced-price meals and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information
with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews,
and law enforcement officials to help them look into violations of program rules.
In accordance with federal law and United States Department of Agriculture (USDA) policy, participating institutions are prohibited from
discrimination on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Office of
Adjudication, 1400 Independence Avenue, SW, Washington, DC, 20250-9410, or call toll-free 866-632-9992 (Voice). Individuals who are hearing-
impaired or have speech disabilities may contact USDA through the Federal Relay Service at 800-877-8339 or 800-845-6136 (Spanish). USDA is
an equal opportunity provider and employer.
Oklahoma State Department of Education Eligibility Documentation, July 2012
E-63
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