Iowa Eligibility Application Form Page 4
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4Name of adult completing form______________________________________________
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hawk-i /Medicaid Information Form: Read this information and sign if you do not want your name released to
hawk-i or Medicaid.
If your children do not have health insurance, many families getting free and reduced price meals can also get free or low-cost health insurance for their
children.
The law requires schools to share your free and reduced price meal eligibility information with Medicaid and hawk-i, the State’s medical insurance
program for children. Specifically, we will give them your child’s name and your name and address. Medicaid and hawk-i can only use the information to
identify children who may be eligible for free or low-cost health insurance and then to contact you. They are not allowed to use the information from your
free and reduced meal application for any other purpose.
Childcare organizations may share this information at their option.
You are not required to allow us to share information from your children’s free and reduced price meal application with Medicaid or the hawk-i program.
It will not affect your children’s eligibility for free and reduced price meals. If you do NOT want your information shared with Medicaid or hawk-i, you must
tell us by completing the information below at the time you complete this eligibility application. If you want further information, you may call hawk-i at 1-800-
257-8563.
I DO NOT want school/home sponsor/child care or Head Start center officials to share information from my free and reduced price meal
application with Medicaid or hawk-i. Also, if you are already receiving Medicaid or hawk-i, please sign below. This will avoid another contact.
Child’s Name: ____________________________________
School/Child Care/Head Start Center:_____________________
Child’s Name: ____________________________________
School/Child Care/Head Start Center:_____________________
Child’s Name: ____________________________________
School/Child Care/Head Start Center:_____________________
Parent/Guardian Name (Printed)_________________________________ Signature_______________________________________ Date_________
Self-Employment Income Worksheet: This worksheet will assist you in calculating the amount to report if you
engage in farming, are self employed or have income from other sources.
Persons who are engaged in farming or who operate other types of private businesses may experience variations in cash flow or monthly income
throughout the year. These persons may use their income tax records from the preceding calendar year as a basis for applying for the free and reduced
price meals. The income to be reported is income derived from the business venture less operating costs incurred in the generation of that income.
Deductions for personal expenses such as medical expenses and other non-business deductions are not allowed in reducing gross business income.
If you have additional income from other kinds of employment, this income must be treated as separate and apart from the income generated from your
business venture. USDA DOES NOT recognize income the same way as IRS. USDA does not permit a loss from a business venture to off-set earnings
from wages or salary. Though your business may have suffered a net operational loss, for purposes of this application, it is not possible to have a negative
income. The least self employed income possible is zero (no income). For example, if you operated a business at a net loss but held another job
where you received wages, your income for purposes of applying for free or reduced price meals would be the income from your wages only. The loss
from the business cannot be deducted from the amount of the income earned in the other job.
A prior year loss from farming or other private business operation cannot be used to reduce the current year net income for determining free and
reduced price eligibility. Wages paid to a spouse or other family member in the operation of a farm or private business must be shown as household
income in Part 5 of the application.
Income from private business operations is to be taken from your most recent U.S. Individual Income Tax Return - Form 1040. Use the lines
from the 1040 that are identified.
Line 12 - Business income or (loss)
$
Line 13 - Capitol gain or (loss)
$
Line 14 - Other gains or (losses)
$
Line 17 - Rental real estate, royalties, partnerships, S corporations, trusts, etc.
$
Line 18 - Farm income or (loss)
$
Total
$
Total 12* = ______________________
The least income possible is zero (a negative number cannot be reported)
*Enter amount in the “All Other Income Last Month” column in Part 5 on the front of the Iowa Eligibility Application.
Optional Waiver Information (for Schools only)
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