Application For Educational Benefits (Page 2 of 4) in pdf

Instructions for Completing the Application for Educational Benefits

If your household currently participates in FOOD SUPPORT (STAMPS), MINNESOTA FAMILY INVESTMENT PLAN

(MFIP) or FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS (FDPIR):

1: Check the box if this is the first school meal application for any of your children at this school district or nonpublic school.

2: Check the box labeled “All children in the household.” List each child’s name, date of birth, grade, and school.

3: List the active case number and check the public assistance program. Do not list a case number from Medical Assistance.

4: Leave this section blank.

5: If your children are approved for meal benefits, this information may be shared with state of Minnesota health insurance programs to

identify eligible children. Leave the boxes blank to allow sharing of information.

6: An adult household member must sign the form. Their Social Security number is not needed.

If you are applying for a FOSTER CHILD (child living in your household who remains the legal responsibility of a welfare agency or

court):

1: Check the box if this is the first school meal application for this child at this school district or nonpublic school.

2: Check the box labeled “one foster child” and check the box to indicate that the foster child receives no income for personal use, or

write in the amount of personal use income to the foster child. Write in the foster child’s name, date of birth, grade and school. Use a

separate application for each foster child.

3: Leave this section blank.

4: Leave this section blank.

5: If your child is approved for meal benefits, this information may be shared with state of Minnesota health insurance programs to

identify eligible children. Leave the boxes blank to allow sharing of information.

6: An adult household member must sign the form. Their Social Security number is not needed.

ALL OTHER HOUSEHOLDS (including WIC households):

Complete an Application for Educational Benefits if your household income is less than or equal to the amount shown for your

household size in this chart. These amounts are effective July 1, 2010, through June 30, 2011.

Household Size

$ Per Year

$ Per Month

$ Twice Per Month

$ Per 2 Weeks

$ Per Week

20,036

1,670

835

771

386

26,955

2,247

1,124

1,037

519

33,874

2,823

1,412

1,303

652

40,793

3,400

1,700

1,569

785

47,712

3,976

1,988

1,836

918

54,631

4,553

2,277

2,102

1,051

61,550

5,130

2,565

2,368

1,184

68,469

5,706

2,853

2,634

1,317

For each additional

6,919

577

289

267

134

household member add:

1: Check the box if this is the first school meal application for any of your children at this school district or nonpublic school.

2: Check the box labeled “All children in the household.” List each child’s name, date of birth, grade and school. If a child receives

regular income, such as SSI payments or wages from a job, list the amount and how often it is received in the last column. Do not list

occasional earnings like babysitting.

3: Leave this section blank.

4: Report all incomes for all adult household members.

Names: List the first and last name of each adult living in your household, related or not (such as grandparents, other relatives or

friends), including yourself. Include a household member temporarily away from home, such as a college student. Attach another

page if necessary.

No Income: Check this column if a person has no income.

Gross Monthly Wages and Salaries: Next to each adult’s name list the gross income earned from work before taxes and other

deductions (not take-home pay). Next to each amount, write in how often the income is received for example: weekly (W), bi-

weekly (every other week) (BW), twice per month (TM), monthly (M) or yearly (Y). If income fluctuates, list expected annual

gross income or average monthly income.

All Other Incomes: List all other amounts received on a regular basis from any source. For self-employment or farm income, list

annual net income after deduction of business expenses (generally reported on a Schedule C or Schedule F of federal tax return).

5: If your children are approved for school meal benefits, their approval status may be shared with state of Minnesota health insurance

programs to identify eligible children. Leave the boxes blank to allow sharing of information.

6: An adult household member must sign the Application for Educational Benefits and provide their Social Security number. If the

person signing the form does not have a Social Security number, they must indicate this by checking the box.

Application For Educational Benefits Page 2

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