Application For Free And Reduced Price School Meals Template

2015-2016 Application for Free and Reduced Price School Meals

Approval Date:

Complete one application per household. Please use a PEN (not a pencil).

Approved for:

STEP 1

(if more spaces are required for additional names, attach another sheet of paper)

List ALL Household Members who are infants, children, and students up to and including grade 12

Homeless,

Student? Yes

School Name:

Foster

Migrant,

Child’s Last Name

Child’s First Name

Definition of Household

Child

Runaway

Member: “Anyone who is

living with you and shares

income and expenses, even

if not related.”

Children in Foster care and

children who meet the

definition of Homeless,

Migrant or Runaway are

eligible for free meals. Read

How to Apply for Free and

Reduced Price School

Meals for more information.

Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR? Circle one: Yes / No

STEP 2

Case

If you answered NO → Go to Step 3 and complete.

If you answered YES → Write a case number here then go to STEP 4 (Do not complete STEP 3)

Number:

Write only one case number in this space.

Report Income for ALL Household Members

(Skip this step if you answered ‘Yes’ to STEP 2)

STEP 3

How often?

A. Child Income

Child income

Weekly

Bi-Weekly 2x Month Monthly

Please read How to

Sometimes children in the household earn income. Please include the TOTAL income earned by all Household Members

Apply for Free and

listed in STEP 1 here.

Reduced Price School

Meals for more

B. All Adult Household Members (including yourself)

information. The

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

Sources of Income for

whole dollars only. If they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.

Children section will

How often?

help you with the Child

Public Assistance/

Pensions/Retirement/

Name of Adult Household Members (First and Last)

Earnings from Work

Child Support/Alimony

All Other Income

Weekly Bi-Weekly 2x Month Monthly

Weekly

Bi-Weekly 2x Month Monthly

Income question. The

Sources of Income for

Adults section will help

you with the All Adult

Household Members

section.

Total Household Members

Last Four Digits of Social Security Number (SSN) of

X X

Check if no SSN

(Children and Adults)

Primary Wage Earner or Other Adult Household Member

STEP 4

Contact information and adult signature

“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give

false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.”

Street Address (if available)

Apt #

City

State

Zip

Daytime Phone and Email (optional)

Printed name of adult completing the form

Signature of adult completing the form

Today’s date