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

Social Security Number / Complete Application

The National School Lunch Act requires that unless an active MFIP, Food Stamp or FDPIR assistance number is supplied for your child or you are applying for a foster child, the

household member signing the application must provide their Social Security number or indicate that they do not have a Social Security number. Provision of a Social Security number

is not mandatory, but if a Social Security number is not given or an indication is not made that the signer does not have such a number, the application cannot be approved.

To be complete, an application based on public assistance must include children's names, assistance numbers and signature of an adult household member. A complete application

based on household income must include the names of all household members, the amounts of income received by all adult household members, the signature of an adult household

member and the Social Security number of the household member completing the application or an indication that they have no Social Security number. A complete application for a

foster child must include the child's name, the amount of any income received for the child's personal use and the signature of an adult household member.

Verification

The school and the Minnesota Department of Education may use the information provided on this form in carrying out efforts to verify the correctness of household size and income

and public assistance information stated on the application. These verification efforts may be carried out through program reviews, audits and investigations and may include

contacting state agencies such as the Minnesota Departments of Economic Security, Human Services or Revenue to verify income or current approval for public assistance. These

efforts may result in a loss or reduction of benefits, administrative claims or legal actions if incorrect information is reported.

Privacy of Information That You Provide on This Form

Information that you provide on this form is private data. The information is used to determine and verify whether children in your household qualify for free or reduced-price school

meals and for administration and enforcement of the lunch and breakfast programs. We may share your 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. The

information you provide on this application is not released for any other purpose unless a parent or guardian requests the release in writing.

Privacy of Your Child's Eligibility Status

Your child's eligibility status for school meals (qualified for "free," "reduced-price" or "paid" meals) is private data used by the school officials who need to know the information to

provide the correct school meal benefit to your child. At public school districts, each student's eligibility status is also recorded on a statewide computer system used to report student

data to the Minnesota Department of Education as required by state law. The Minnesota Department of Education uses this information to: (1) administer state and federal programs;

(2) calculate compensatory revenue for public schools; and, (3) judge the quality of the state's educational program.

Federal law allows a school to release a child's meal eligibility status to officials of the following types of programs without household consent: (1) federal education program; (2) state

health or education program administered by the school or a state agency; and (3) federal, state or local nutrition program that has participation requirements similar to the National

School Lunch Program. School officials may send information about other programs or benefits that may be of interest to households that have qualified for free or reduced-price

school meals. School meal eligibility information is also used for statistical reports, without individual identification. A child's eligibility status will not be released for any other

purpose unless a parent or guardian requests the release in writing.

Sharing Information with MinnesotaCare and General Assistance Medical Care Programs

Children who are eligible for free and reduced-price school meals may be eligible for Minnesota health insurance programs. Your child’s eligibility status for school meals (qualified

for free or reduced-price meals) may be shared with the MinnesotaCare and General Assistance Medical Care programs unless you tell us not to share your information by checking

the boxes in section 5 of the application. You are not required to share information for this purpose and your decision will not affect approval for school meal benefits.

Civil Rights Survey (voluntary)

Non-discrimination Statement: This explains what to do if

This information is requested solely for the purpose of determining compliance with federal

you believe you have been treated unfairly. In accordance

civil rights laws, and will not affect your application. By providing this information, you

with federal law and U.S. Department of Agriculture policy, this

will assist us in assuring that this program is administered in a nondiscriminatory manner.

institution is prohibited from discrimination on the basis of race,

1. Ethnicity

(check one)

color, national origin, sex, age or disability. To file a complaint

Hispanic or Latino