2014-2015 Household Meal Benefit Application Form printable pdf download

DO NOT STAPLE IN THIS CORNER!

Board of Education of Allegany County-Food & Nutrition Services-P.O. Box 1724-Cumberland, MD 21501-1724

H-ID Number

HOUSEHOLD MEAL BENEFIT APPLICATION – 2014-2015

Complete this form. Sign your name and return the form to the school. For help call the school office.

PART 1. STUDENT INFORMATION – Check (ü ) the box if foster child. If all listed children are foster children, skip to Part 5

Student’s Name

Grade

School

Pupil #

Student’s Name

Grade School

Pupil #

q

1. ______________________________________

_____ ________ __________ 5. ______________________________________

______ ________ __________

q

2. ______________________________________

______ ________ _________ 6. ______________________________________

______ ________ __________

q

3. ______________________________________

______ ________ __________ 7. ______________________________________

______ ________ __________

q

4. ______________________________________

______ ________ _________ 8. ______________________________________

______ ________ _________

PART 2. CASE NUMBER If applicable, give a Food Supplement Program (FSP) or Temporary Cash Assistance (TCA) case number for any member of

the household (9 digit Client ID number from approval letter) ___ ___ ___ ___ ___ ___ ___ ___ ___.If completed, skip to Part 5. Last four digits of

Social Security Number are not needed.

PART 3. IF ALL CHILDREN YOU ARE APPLYING FOR IS HOMELESS, MIGRANT, OR RUNAWAY CHECK THE APPROPRIATE BOX

AND CALL YOUR SCHOOL, MIGRANT COORDINATOR, HOMELESS LIAISON Sheree Witt, Director (301759-2064) and skip to Part 5.

q HOMELESS q MIGRANT q RUNAWAY

PART 4. HOUSEHOLD MEMBERS & GROSS INCOME -

You must tell how much and how often (i.e., weekly, every other week, twice a month, or monthly).

Example: $199.99/weekly, $149.99/every other week, $99.99/twice a month, or $50.00/monthly

NAMES OF ALL HOUSEHOLD

EARNINGS FROM WORK

ADDITIONAL INCOME

ALL OTHER

Check

MEMBERS

(before deductions)

Child Support, Alimony, TCA, Pensions,

INCOME

if NO

(Include the student(s) named above)

Retirement, Social Security, SSI, VA Benefits

Income

How Often

Income

How Often

Income

How Often

q

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 must list the last four digits of his/her Social

Security Number or check (ü ) the “I do not have a SSN” box below.

I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will receive Federal funds

based on the information 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. I understand my child’s eligibility status may be shared as allowed by law.

Sign here: ____________________________________ Print name:_________________________________ Date: _________________

Address: _________________________________________________________________ Phone Number ________________________

City: ______________________ State: _____ Zip Code: ______Social Security Number:

____ q I do not have a SSN

XXX-XX - ____ ____ ____

PART 6. SHARING INFORMATION WITH OTHER PROGRAMS

The eligibility status of your children may be used for other authorized purposes, shared with local Title I officials, and used for National Assessment of

Educational Progress analyses. Your family may also be eligible to receive benefits under the Food Supplement Program (FSP) or the Women, Infants, and

Children (WIC) Program. To share your information with these programs, we must have your permission. Your decision will not change whether your

children receive free or reduced price meals. If you want information shared with FSP or WIC, check (ü ) the YES box below.

You may be contacted about submitting an application for the FSP or WIC.

q

q WIC

Yes, I want information shared from the Free and Reduced-Price Meal Application with

FSP and/or

Children eligible for free or reduced-price school meals may also be able to get free or low-cost health insurance through Medicaid or the MD Children’s

Health Insurance Program (MCHIP). The law allows us to inform Medicaid and MCHIP that your children are eligible for free or reduced price meals, unless

you say No. Your decision will not change whether your children receive free or reduced-price meals.

q

If you do not want information shared with Medicaid or the MCHIP, check (ü )

No.

_______________________DO NOT FILL OUT THIS PART - FOR FOOD & NUTRITION SERVICES USE ONLY__________________________

Per: q Week, q Every 2 Weeks, qTwice A Month, q Monthly, qYear

Household size _____ TOTAL INCOME ____________________________

ELIGIBILITY ____________________________

____________________

DETERMINING OFFICIAL