F R D

Attachment IIIA

F R D

School Year 20032004

Date withdrew________

APPLICATION FOR FREE AND REDUCED PRICE SCHOOL MEALS/MILK

To apply for free and reduced price meals for your children, read the instructions on the back, complete this form, sign your name and return it to the school.

Call _________ ________________________________________ if you need help. For additional names, list on a sheet of paper.

CHILDREN IN SCHOOL: (

Complete a

separate

application for each foster child.)

Children’s Names (Last, First, MI)

Grade/Teacher

School

FOSTER CHILD:

If the above named child is the legal responsibility of a welfare agency or court, check this box.

List the child’s personal use income: (Write “0” if the child has no personal use income.) Skip to Part 5.

3. HOUSEHOLDS GETTING FOOD STAMPS OR AID TO DEPENDENT CHILDREN(ADC)/TEMPORARY ASSISTANCE TO

NEEDY FAMILIES (TANF):

Complete this section and sign the application in Part 5

submit a Direct Certification letter from the

Office of Temporary and Disability Assistance. Complete a separate application for children with a different case number or no case

number.

Food Stamp #: ADC/TANF #:

HOUSEHOLD MEMBERS & TOTAL HOUSEHOLD INCOME:

If you did not give a food stamp or ADC/TANF number, or submit

a Direct Certification letter, complete this part and all of part 5.

Show how often each amount is received.

See Examples

CURRENT INCOME/PAY PERIOD

Examples

: $100/

weekly

, $100/

biweekly

, $100/

2x per month

, $100/

monthly

If pay period is not noted, the reviewing official will process the reported income amount as received WEEKLY.

List the names of everyone in your household

Earnings From Work

Before deductions

Child Support,

Alimony, Etc.

Payments from

Pension or Retirement

Other Income

Amount / How Often

$ /

Amount / How Often

$ /

Amount / How Often

$ /

Amount / How Often

$ /

5. SIGNATURE:

An adult household member MUST sign the application before it can be approved.

I certify that all of the information is true and that all income is reported. I understand that the information is being given for the school to receive federal

funds; that school officials may verify the information and that deliberate misrepresentation of the information may subject me to prosecution under

applicable State and federal laws, and my children may lose meal benefits.

SIGNATURE:

___________________________________

DATE:

SOCIAL SECURITY #___ ___ ______ ______ ___ ___ ___

_________

Home Telephone Work Telephone Mailing Address Zip Code

SOCIAL SECURITY NUMBER:

Part 4

is completed, the adult who signs the application

must

provide his/her Social Security

number.

MONTHLY INCOME CONVERSION: WEEKLY X 4.33; EVERY 2 WEEKS X 2.15; TWICE A MONTH X 2

FOOD STAMP, ADC/TANF, FOSTER CHILD

INCOME HOUSEHOLD: Total Household Monthly Income: ________________________________ Household Size: ______________________

Application APPROVED for:

Free Meals

Reduced Price Meals

Temporary Free (expires in 45 days)___/___/___

Application DENIED

Date Notice Sent: __________________ Signature of Reviewing Official: __________________________________________ Date: _________________

DO NOT WRITE BELOW THIS LINE – FOR SCHOOL USE ONLY

APPLICATION INSTRUCTIONS

To apply for free and reduced price meals, submit a Direct Certification letter received from the Office of Temporary and Disability Assistance

OR complete this application using the instructions for your household. Sign the application and return the application to the school. Please

complete a separate application for each foster child. Call the school if you need help: ____________________. Ensure that all information is

provided. Failure to do so may result in denial of benefits for your child or unnecessary delay in approving your application.

PART 1 ALL HOUSEHOLDS MUST COMPLETE STUDENT INFORMATION.

(1)

Print the names of the children for whom you are applying.

(2)

List their grade and school.

PART 2 HOUSEHOLDS WITH A FOSTER CHILD SHOULD COMPLETE THIS PART AND SIGN PART 5.

A foster child

is the legal responsibility of a welfare agency or court. A separate application must be completed for each foster child.

(1)

List the foster child’s monthly “personal use” income. (“Personal Use” income is money given by the welfare office

identified by category for the child’s personal use, such as an allowance, and all other money the child gets, such as

money from his/her family or money from the child’s employment.) Write “0” if the foster child does not get “personal

use” income. SKIP PART 4. Do not list any other children, household members or income, or a social security number.

(2)

A foster parent or other official representing the child must sign the application in PART 5.

PART 3 HOUSEHOLDS GETTING FOOD STAMPS, ADC/TANF OR FDPIR SHOULD COMPLETE THIS PART AND

SIGN PART 5.

(1)

List a current food stamp case number, ADC/TANF or FDPIR (Food Distribution Program for Indian Reservations)

number. Complete a separate application for a child/children with a different case number.

(2)

An adult household member must sign the application in PART 5. SKIP PART 4. Do not list names of household

members or income if you list a food stamp case number, ADC/TANF or FDPIR number.

PARTS 4 & 5 ALL OTHER HOUSEHOLDS MUST COMPLETE THESE PARTS AND ALL OF PART 5.

(1)

Write the names of everyone in your household, whether or not they get income. Include yourself, the children you are

applying for, all other children, your spouse, grandparents, and other related and unrelated people in your household.

Use another piece of paper if you need more space.

(2)

Write the amount of current income each household member receives, before taxes or anything else is taken out, and

indicate where it came from, such as earnings, welfare, pensions and other income. If the current income was more or

less than usual, write that person’s usual income.

Specify how often this income amount is received: weekly, bi

weekly, monthly, 2 x per month.

(3)

The value of any child care provided or arranged, or any amount received as payment for such child care or

reimbursement for costs incurred for such care under the Child Care and Development Block Grant, TANF and At Risk

Child Care Programs should

not

be considered as income for this program.

(4)

The application must include the social security number of the adult who signs

PART 5

if Part 4 is completed. If the

adult does not have a social security number, write “none”. If you listed a food stamp, ADC/TANF or FDPIR number, or

if you are applying for a foster child, a social security number is not needed.

OTHER BENEFITS:

Your child may be eligible for benefits such as Medicaid or Children’s Health Insurance Program (CHIP). In order to

determine if your child is eligible, program officials need information from your free and reduced price meal application. Your written consent

is required before any information may be released. Please refer to the attached parent Disclosure Letter and Consent Statement for information

about other benefits.

PRIVACY ACT STATEMENT

Section 9 of the National School Lunch Act requires that unless your children’s food stamp, ADC/TANF or FDPIR case number is provided,

you must include the social security number of the adult household member signing the application, or indicate that the household member does

not have a social security number. 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. The social security number may be used to identify the household member in carrying out efforts

to verify the correctness of information stated on the application. These verification efforts may be carried out through program reviews, audits

and investigations and may include contacting employers to determine income, contacting a food stamp or welfare office to determine current

certification for receipt of food stamps or other benefits, contacting the State employment security office to determine the amount of benefits

received and checking the documentation produced by household members to prove the amount of income received. These efforts may result in

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

DISCRIMINATION COMPLAINTS

In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color,

national origin, sex, age, or disability. To file a complaint, write to USDA, Director, Office of Civil Rights, Room 326W, Whitten Building, 1400

Independence Avenue, SW, Washington DC 202509410 or call 2027205964(voice and TDD). USDA is an equal opportunity provider and employer.