Iowa Eligibility Application Form (Page 2 of 4) in pdf

05/14

Income Guidelines effective July 1, 2014

If you have other questions or need help, call 641-484-9000.

Household Size

Federal Income Chart

Yearly

Monthly

Twice per Month

Every Two Weeks

Weekly

21,590

1,800

900

831

416

29,101

2,426

1,213

1,120

560

36,612

3,051

1,526

1,409

705

44,123

3,677

1,839

1,698

849

51,634

4,303

2,152

1,986

993

59,145

4,929

2,465

2,275

1,138

66,656

5,555

2,778

2,564

1,282

74,167

6,181

3,091

2,853

1,427

For each additional

person:

7,511

626

313

289

145

Households: Your children may qualify for reduced or free price meals if your household income falls within the limits on this chart.

Privacy Act Statement: This explains how we will use the information you give us.

The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the

information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of

the social security number of the adult household member who signs the application. The last four digits of the social security

number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP),

Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case

number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does

not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals

and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility 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.

Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. “The U.S. Department

of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color,

national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or

parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or

protected genetic information in employment or in any program or activity conducted or funded by the department. If you wish to file

a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found at

or at any USDA office, or call (866) 632-9992 to request the form. You may

also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail

at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S. W., Washington D.C. 20250-

9410, by fax (202) 690-7442 or email at program.intake@usda.gov. Individuals who are deaf, hard of hearing or have speech

disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an

equal opportunity provider and employer. ”

Iowa Non-Discrimination Notice:“It is the policy of this CNP provider not to discriminate on the basis of race, creed, color, sex,

sexual orientation, gender identity, national origin, disability, or religion in its programs, activities, or employment practices as

required by the Iowa Code section 216.7and 216.9. If you have questions or grievances related to compliance with this policy by this

CNP Provider, please contact the Iowa Civil Rights Commission, Grimes State Office Building, 400 E. 14th St., Des Moines, IA

50319-1004; phone number 515-281-4121, 800-457-4416; web site: https://icrc.iowa.gov/.”

Iowa Eligibility Application Form Page 2

Related Articles

Related forms

Related Categories