Application For Educational Benefits (Page 3 of 4) in pdf

Application for Educational Benefits

Free and Reduced-Price School Meals

School Year 2010-11

State and Federally Funded Programs for Schools

Check here if this is the first school meal application at this school district or this nonpublic school for any child listed below.

All children in the household

I have listed below

except foster children, from birth through high school. Attach an additional page, if necessary.

(check one):

One foster child

in my care (who is the legal responsibility of a social services agency or court). Write in the foster child’s name, date of birth, grade and

school below. Does this foster child receive foster care funds that are designated specifically for the child’s personal use?

Yes - $________.

Complete a separate application for each foster child. Do not combine foster children and other children on this form.

If applicable

Names of all Children in Household

except Foster Children

Regular

Active Case Number

(or Name of One Foster Child)

Date of Birth

School

Grade

Income

to Child

For any household member

Month/Day/Year

(for example SSI)

First Name

Last Name

____/____/____

$________ per________

Case Number: _____________

____/____/____

MFIP

$________ per________

____/____/____

Food Support (Stamps)

$________ per________

FDPIR

____/____/____

$________ per________

____/____/____

(Not Medical Assistance)

$________ per________

List all adults in the household, all incomes and how often each income is received. Attach an additional page, if necessary. The instructions page shows the maximum income to

qualify for school meal benefits.

Do not complete Section 4

if a foster child is listed in Section 2 or a case number is provided in Section 3.

Household Incomes

Write in each gross income and how often it is received: weekly (W), bi-weekly (every other

week)

(BW),

twice per

Names of all Adults in Household

month

(TM),

monthly (M)

yearly

(Y). Do not write in hourly pay. If income fluctuates, write in the amount

(all household members not listed in Section 2)

normally received.

Check this

column if

Gross Wages and Salaries

Pension, SSI,

Public Assistance,

Unemployment,

Any Other Income,

person has

from all jobs

Retirement,

Child Support,

Worker’s

including net Farm/

First Name

Last Name

NO INCOME

- before deductions -

Social Security

Alimony

Compensation,

Self-Employment

Strike Benefits

______

_____

per

______

_____

per

______

_____

per

If your children are approved for school meal benefits, this information may be shared with MinnesotaCare and General Assistance Medical Care programs to identify children

eligible for Minnesota health insurance programs. See back page for more information. Leave the boxes blank to allow sharing of information.

not

share my information with the MinnesotaCare health insurance program.

not

share my information with the General Assistance Medical Care program.

I certify that the information provided on this application is true and correct and that I have reported all household members and all household incomes. Because federal and

state funds may be paid on the basis of this information, I understand that school and state officials may verify the information, and that deliberate misrepresentation may

subject me to prosecution under applicable laws.

Signature

of Adult Household Member (required) ___________________________________ Print Name: _________________________________ Date: ________

Social Security number

(required if Part 4 is completed): ___ ___ ___ - ___ ___ - ___ ___ ___ ___ OR

I don’t have a Social Security number

Address: _________________________________________ City ___________________________Zip__________ Home Phone: ________________ Work Phone: ________________

Total Household Size: _____ Total Incomes:$ __________ per ________

Date Verification Sent: _____________ Response Due: _____________ 2

Notice Sent: _______________

Or Household Is Categorically Eligible: ______ (MFIP/Food Assistance (Stamps)/FDPIR)

Approved: Free ____ Reduced-Price ____

Temporary until _____, _____, _____

Result: No Change ___ Free to Reduced-Price ___ Free to Paid ___ Reduced-Price to Free ___ Reduced-Price to Paid ___

Denied: Incomplete ____ Income Too High ____ Other:

Reason for Change: Income____ Household Size ____ Refused Cooperation ____ Other:____________________________

Signature of Determining Official: ________________________________ Date:________

Date 'Notice of Change' Sent: ____________

Withdrawn:_________