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FREE AND REDUCED PRICE SCHOOL MEALS FAMILY APPLICATION |
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Part 1. Children in School (Use a separate application for each foster child) |
Part 2. Food Stamp/ Cash Assistance/ FDPIR Case Number For EACH Student |
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Names of all
children in school |
School Name |
Grade |
If your child(ren) have a Case Number please enter below for each student. Skip to Part 6. |
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Part 3. If the child you are applying for is homeless, migrant, or a runaway check the appropriate box and call (your school, homeless liaison, migrant coordinator at phone #) Homeless q Migrant q Runaway q |
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Part 4. Foster Child |
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If this application is for a child who is the legal responsibility of a welfare agency or court, check this box q and then list the amount of the child’s personal use monthly income: $__________. Skip to Part 6. |
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Part
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1. Name
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2. Check if NO Income |
3. GROSS INCOME and HOW OFTEN it was received Example: $50–monthly $50–twice a month $50–every other week $50–weekly |
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Earnings from work before deductions |
Welfare, child support, alimony |
Pensions, retirement, Social Security |
All Other Income |
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How Much |
How Often |
How Much |
How Often |
How Much |
How Often |
How Much |
How Often |
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Part 6. Signature and Social Security Number (Adult must sign) |
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An adult household member must sign the application. If Part 5 is completed, the adult signing the form must also list his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on the back of this page.) I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted. |
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Must Sign here: X____________________________________Print name:_________________________ Date:_ _ / _ _ / _ _ Social Security Number: __ __ __ - __ __ - __ __ __ __ q I do not have a Social Security Number |
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Address:__________________________________________________________APT#______ Phone #:(_ _ _) _ _ _ - _ _ _ _ |
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Part 7. Children’s racial and ethnic identities (optional) |
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Mark one or more racial identities: Mark one ethnic identity: |
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q Asian q American Indian or Alaska Native q Black or African American q Hispanic or Latino q White q Native Hawaiian or Other Pacific Islander q Other q Not Hispanic or Latino |
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Don’t fill out this part. This is for school use only. |
qError-Prone qDirectly Certified – Attach to match result |
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Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24 Monthly x 12 |
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Total Income: $___________ Per: qWeek, qEvery 2 Weeks, qTwice A Month, qMonth, qYear Household size: __________ |
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qCase # Application Eligibility: qFree, qReduced, qDenied -- Reason: _________________ Date Withdrawn: _ _ / _ _ / _ _ |
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qTemp. Free – Zero Income (45 days) qTemp. Free – homeless/migrant/runaway (30 days) Temporary Free Expires: _ _ / _ _ / _ _ |
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Determining Official’s Signature: _______________________________ Date: _ _ / _ _ / _ _ Confirming Official’s Signature: ________________________________ Date: _ _ / _ _ / _ _ Follow-up Official’s Signature: _________________________________ Date: _ _ / _ _ / _ _ |
Date Notice Sent: _ _ / _ _ / _ _ |
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qSelected for Verification (see attachment) |
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