Free and Reduced Price School Meals

Household Application

   

school year 2008 - 2009

Instructions For School Districts

This packet contains:                

 

Required information that must be provided to households:

  • Letter to Households
  • Free and Reduced Price School Meals Application

 

Optional application-related materials that may be provided to households:

·         Sharing Information With Medicaid/CHIP 

·         Sharing Information With Other Programs

 

The pages are designed to be printed on 8½” by 11” paper. Some pages may be printed front and back. You will need to identify the benefits that are offered in your school, such as afterschool snacks. [Bold bracketed fields] indicate where you need to insert school district specific information. If you make changes, you must submit your application package to your State agency for approval.

 

This prototype application package includes information regarding the exclusion of housing allowance for those in the Military Housing Privatization Initiative.  If this is not pertinent to your school district, please modify as appropriate.

 

If you have questions, contact:

 

Sandy Souder, Administrator

School Nutrition Programs

800 331-0129, Extension 76833

ssouder@state.pa.us

 

 

 

 

Dear Parent/Guardian:

Children need healthy meals to learn. Wayne Highlands offers healthy meals every school day. Breakfast costs $1.25; lunch costs $1.75 grades K-5 and $2.00 for grades 6-12.. Your children may qualify for free meals or reduced price meals. Reduced price is $.30 for breakfast and $.40 for lunch.

1. Do I need to fill out an application for each child?  No. Complete the application to apply for free or reduced price meals. Use one Free and Reduced Price School Meals Application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to: 474 Grove Street, Honesdale, PA  18431.

2. Who can get free meals? Children in households getting Food Stamps or TANF and most foster children can get free meals regardless of your income. Also, your children can get free meals if your household income is within the free limits on the Federal Income Guidelines.

3. Can homeless, runaway and migrant children get free meals?  Please call [school, homeless liaison or migrant coordinator] to see if your child(ren) qualify, if you have not been informed that they will get free meals.

4. Who can get reduced price meals? Your children can get low cost meals if your household income is within the reduced price limits on the Federal Income Chart, shown on this application.

5. Should I fill out an application if I got a letter this school year saying my children are approved for free or reduced price meals? Please read the letter you got carefully and follow the instructions. Call the school at 253-6083 if you have questions.

6. I get WIC. Can my child(ren) get free meals? Children in households participating in WIC may be eligible for free or reduced price meals. Please fill out an application.

7. Will the information I give be checked? Yes, we may ask you to send written proof.

8. If I don’t qualify now, may I apply later? Yes. You may apply at any time during the school year if your household size goes up, income goes down, or if you start getting Food Stamps, TANF or other benefits. If you lose your job, your children may be able to get free or reduced price meals.

9. What if I disagree with the school’s decision about my application? You should talk to school officials. You also may ask for a hearing by calling or writing to: Thomas Jenkins 570-253-4661

10. May I apply if someone in my household is not a U.S. citizen? Yes. You or your child(ren) do not have to be a U.S. citizen to qualify for free or reduced price meals.

11. Who should I include as members of my household? You must include all people living in your household, related or not (such as grandparents, other relatives, or friends). You must include yourself and all children who live with you.

12. What if my income is not always the same? List the amount that you normally get. For example, if you normally get $1000 each month, but you missed some work last month and only got $900, put down that you get $1000 per month.  If you normally get overtime, include it, but not if you get it only sometimes. 

13. We are in the military, do we include our housing allowance as income? If your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. All other allowances must be included in your gross income.

 

If you have other questions or need help, call 570-253-6083.

Si necesita ayuda, por favor llame al teléfono: 570-253-6083.

 

Sincerely,                                                              Karen Carlson, MS,RD Food Service Director                              


INSTRUCTIONS FOR APPLYING

If your household gets FOOD STAMPS OR TANF, follow these instructions:

Part 1: List child(ren)’s name, school, grade, and a Food Stamp or TANF case number.

Part 2: Check the appropriate box, if any.

Part 3: Skip this part.

Part 4: Skip this part.

Part 5: Sign the form. A Social Security Number is not necessary.

Part 6: Answer this question if you choose to.

 

Check the appropriate box and contact [your school, homeless liaison, migrant coordinator].

Fill out application by following instructions for ALL OTHER HOUSEHOLDS.

 

If you are applying for a FOSTER CHILD, follow these instructions:

Part 1: Use a separate application for each foster child. List the child’s name, school, and grade.

Part 2: Skip this part.

Part 3: Check the box and list the child’s personal use monthly income, if any.

Part 4: Skip this part.

Part 5: Sign the form. A Social Security Number is not necessary.

Part 6: Answer this question if you choose to.

 

ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:

Part 1: List each child’s name, school, and grade.

Part 2: Check the appropriate box, if any.

Part 3: Skip this part.

Part 4: Follow these instructions to report total household income from last month.

Column 1–Name: List the first and last name of each person living in your household, related or not (such as grandparents, other relatives, or friends). You must include yourself and all children living with you. Attach another sheet of paper if you need to.

Column 2 –Gross income last month and how often it was received.  Next to each person’s name list each type of income received last month, and how often it was received.  For example, Earnings from work:  List the gross income each person earned from work.  This is not the same as take-home pay.  Gross income is the amount earned before taxes and other deductions.  The amount should be listed on your pay stub, or your boss can tell you.  Next to the amount, write how often the person got it (weekly, every other week, twice a month, or monthly).  All other income:  List the amount each person got last month from welfare, child support, alimony, (second column) pensions, retirement, Social Security (third column), and ALL OTHER INCOME SOURCES (fourth column).  In the All Other column, include Worker’s Compensation, unemployment, strike benefits, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), disability benefits, regular contributions from people who do not live in your household, and ANY OTHER INCOME.  Report net income for self-owned business, farm, or rental income.  Next to the amount, write how often the person got it. If you are in the Military Housing Privatization Initiative, do not include this housing allowance.

Column 3–Check if no income: If the person does not have any income, check the box.

Part 5: An adult household member must sign the form and list his or her Social Security Number, or mark the box if he or she doesn’t have one.

Part 6: Answer this question if you choose to.

FREE AND REDUCED PRICE SCHOOL MEALS FAMILY APPLICATION

Part 1. Children in School (Use a separate application for each foster child)

Names of all children in school
(First, Middle Initial, Last)

School Name

Grade

Food Stamp or TANF case # (if any). Skip to Part 5 if you list a Food Stamp or TANF case #

 

 

 

6      4      0      0  ___ ___ ___ ___ ___

 

 

 

___ ___ ___ ___ ___ ___ ___ ___ ___

 

 

 

___ ___ ___ ___ ___ ___ ___ ___ ___

 

 

 

___ ___ ___ ___ ___ ___ ___ ___ ___

 

 

 

___ ___ ___ ___ ___ ___ ___ ___ ___

Part 2. 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

Part 3. Foster Child

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 5.

Part
4. Total Household Gross Income—You must tell us how much and how often

1. Name
(List everyone
in household)

2. Gross income and how often it was received

Example:   $100/monthly   $100/twice a month    $100/every other week   $100/weekly

3. Check
if NO income

Earnings from work before deductions

Welfare, child support, alimony

Pensions, retirement, Social Security

All Other Income

(Example)
Jane Smith

$200/weekly_____

$150/weekly_____

$100/monthly_____

$______/________

q             

 

$______/________

$______/________

$______/________

$______/_______

q             

 

$______/________

$______/________

$______/________

$______/_______

q             

 

$______/________

$______/________

$______/________

$______/_______

q             

 

$______/________

$______/________

$______/________

$______/_______

q             

 

$______/________

$______/________

$______/________

$______/_______

q             

 

$______/________

$______/________

$______/________

$______/_______

q             

 

$______/________

$______/________

$______/________

$______/_______

q             

 

$______/________

$______/________

$______/________

$______/_______

q             

Part 5. Signature and Social Security Number (Adult must sign)

An adult household member must sign the application. If Part 4 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.)                                                  PLEASE PRINT CLEARLY

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.    

Sign here: X_____________________________ Print name: _____________________________Date: ______________ 

Address:_______________________________________________________Phone Number:______________________

Social Security Number:  __ __ __ - __ __ - __ __ __ __    q I do not have a Social Security Number

Part 6. Children’s Racial and Ethnic Identities (optional)

Mark one or more racial identities:                                                                                           Mark one ethnic identity:

q     Asian                                   q American Indian or Alaska Native                                         q Hispanic or Latino

q     White                                   q Native Hawaiian or Other Pacific Islander                            q Not Hispanic or Latino                                                               

q Black or African American  q Other                                                                                            

Don’t fill out this part. This is for school use only.

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24 Monthly x 12

Total Income: ____________ Per: q Week, q Every 2 Weeks, q Twice A Month, q Month, q Year       Household size: ________

Categorical Eligibility: ___  Date Withdrawn: ________Eligibility: Free___  Reduced___  Denied___ Reason: _______________________

Temporary: Free_____  Reduced_____  Time Period: ___________ (expires after _____ days)

Determining Official’s Signature: ________________________________________________ Date: ______________

Confirming Official’s Signature: __________________ Date: _______ Follow-up Official’s Signature: __________________ Date: ______

 

 

FEDERAL INCOME CHART

For School Year 2006-2007

Household size

Yearly

Monthly

Weekly

1

18,130

1,511

349

2

24,420

2,035

470

3

30,710

2,560

591

4

37,000

3,084

712