Montville Schools, CT State Dept. of Education: Child Nutrition Programs

Application For Free or Reduced Price Meals

 

Dear Parents/Guardians: Complete only one application for each household. To apply for free or reduced price meals for your children, you must list the names of all members of the household in Part 5. However, please note: Each foster child must have their own separate application and should not be included as part of your regular household. Return the application to the school office. If the children receive medical benefits only, you must complete

Part 1 and then continue with Part 5.

1.      (Print) Student Information: (Make sure you LIST EACH CHILD below AND in section 5a.)               Does this child receive           

 

Name

 

 

Grade

 

 

Name of School

 

Food Stamps or TFA? (circle)

 

If yes, provide client ID number

 

 

 

 

 

 

yes / no

 

 

 

 

 

 

 

 

yes / no

 

 

 

 

 

 

 

 

yes / no

 

 

 

 

 

 

 

 

yes / no

 

 

 

 

 

 

 

 

yes / no

 

 

 

2.     If the child you are applying for is homeless, migrant, or a runaway, check the appropriate box and contact your schoolÕs homeless liaison at: ____________________________      Homeless Migrant Runaway

 

3.     The children listed above:

 

May Qualify (Continue to complete the application). Do not Qualify (Please initial _________ and return the form).

 

4.     Check if student is a Foster Child: Note: Complete a separate application for each foster child. List the childÕs monthly
personal use income. Write Ò0Ó if the child has no personal use income. $ ______________

5.      Household Members and Monthly Income: If you are receiving only medical benefits, you must report an income and complete Part 5. If you gave a client ID number for Food Stamps or TFA, skip part 5.

a. Name

(List everyone in household
including children listed
above in section 1.)

b. Gross Income and how often it was received (Indicate if income was received monthly,
twice a month, every other week, weekly, or annually.)You MUST list frequency of income.

Example: $100/monthly $100/twice a month $100/every two weeks $100/weekly $28,000/annually

c.

Check if NO income

Earnings from work before deductions

Welfare, child support, alimony

Pensions, retirement, Social Security

All other Income

1

 

$ __________/____________

$__________/____________

$ __________/____________

$__________/____________

2

 

$ __________/____________

$__________/____________

$ __________/____________

$__________/____________

3

 

$ __________/____________

$__________/____________

$ __________/____________

$__________/____________

4

 

$ __________/____________

$__________/____________

$ __________/____________

$__________/____________

5

 

$ __________/____________

$__________/____________

$ __________/____________

$__________/____________

6

 

$ __________/____________

$__________/____________

$ __________/____________

$__________/____________

7

 

$ __________/____________

$__________/____________

$ __________/____________

$__________/____________

PART 6 Ð RACIAL AND ETHNIC IDENTITY: You are not required to answer this question.

 

Ethnicity: Hispanic or Latino Not Hispanic or Latino

Race: White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander

 

7.      Signature and Social Security Number: I certify that all of the above information is true and correct and that all income is reported. I understand that this information is being given for the receipt of Federal funds; that school officials may verify the information on the application; and that deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws.

X ________________________________________ X ___________________________ OR No Social Security Number.

Signature of Adult Household Member                         Social Security Number

 

Home Telephone No. ______________________ Work Telephone No. __________________ Printed Name _______________________________

 

Street/Apt. No. _______________________________________ City/State/Zip ___________________________ Date__________________________

 


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 social security number of the adult household member who signs the application. The social security number is not required when you apply on behalf of a foster child or you list a food Stamp Program, Temporary Family Assistance (TFA) Program or Food Distribution Program on Indian Reservations (FDPIR) case number 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. In accordance with the 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 of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington DC 20250-9410 or call (800) 795-3272 or 202- 720-6382 (TTY). USDA is an equal opportunity provider and employer.

For School Use Only Ð Do Not Write Below This Line

Annual Income Conversion: Weekly X 52 t Every 2 weeks X 26 t Twice a Month X 24 t Monthly X 12

£ Food Stamp/TFA Household

£ Income Household: Total household annual income: _______________________________         Household Size: __________________________________ Application approved for: Free Meals                                      Application denied because:

                                    Reduced-Price Meals                                    Income over allowed amount Incomplete/missing Other

Temporary approved for: Free Meals, Expires: __________________ Reduced-Price Meals, Expires: __________________

 

Date Notice Sent: __________________________ Signature of Determining Official: _______________________________________ Date: _____________________

 

 

APPLICATION INSTRUCTIONS

 

To apply for free and reduced price meals, complete this application using the instructions below, sign your name and return the application to the school. If you need help, call school food services at this number: 860-848-3658

 

Part 1- STUDENT INFORMATION: List each childÕs name, grade, and school. Indicate if your children are receiving Food Stamps or TFA. If your children are receiving Food Stamps or TFA, provide the Client ID Number for each child. An adult household member must sign the application in Part 7, but do not complete Part 5. (Note: If you are receiving only medical benefits for your children, you must report all household income in Part 5.) If a child is a foster child, a separate application must be completed. They are considered a separate household because they are a legal ward of the State and must have a separate application.

Part 2 Ð Indicate if the child you are applying for is homeless, migrant, or a runaway. You must contact the school (or homeless liaison) to
notify them of the childÕs status.

Part 3 Ð Indicate your childrenÕs potential eligibility or ineligibility to qualify for free or reduced price meal benefits.

Part 4 - A FOSTER CHILD who is a legal ward of the State may get free meals regardless of your household income.

Complete a separate application for each foster child, and complete Part 4 and Part 7. Licensed foster homes do not complete Part 5.

[Note: Subsidized adoptions and/or guardianships require you to provide all household income documentation in Part 5. These children are not considered to be legal wards of the state and therefore, are considered part of your household and all household income must be listed.]

FOSTER CHILD INCOME: Write each childÕs *personal use income and how often it is received (such as weekly, every two weeks, twice a month, or monthly). Write Ò0Ó if the child has no personal use income. An Adult household member must sign Part 7.

*Personal use income includes: Funds provided by the welfare agency that are specifically identified by category for the personal use of the child, such as for clothing, school fees, and allowances. Welfare funds paid to the foster parents identified by category for shelter and care, and those identified as special needs funds, such as those for medical and therapeutic needs, are not considered as income. Where welfare funds cannot be identified by category, no portion of the provided funds is considered as income. Personal use income also includes other funds received by the child, including any income the child earns for full-time or regular part-time employment, and money provided by the childÕs family for personal use.

Part 5- ALL OTHER HOUSEHOLDS: Complete Part 5 if: You did not give a Food Stamp/TFA Client ID Number; you are receiving
only medical benefits; each child is not a legal ward of the state; or if each child is a subsidized adoption or you have subsidized
guardianship. Note: An adult household member must sign the application in Part 7.

  1. HOUSEHOLD NAMES: Write the names of everyone (related or unrelated) who live in your household. Include yourself and each child listed above, your spouse, all other children, grandparents, other relatives and unrelated people in your household. Use a separate sheet of paper if you do not have enough space. Note: Do not include foster children in your regular household.
  2. CURRENT INCOME: Write the amount of income each person now gets on the same row as their name in the column that corresponds with the income source. Also indicate if income was received monthly, twice a month, every two weeks, weekly, or annually. Income is all money before taxes or anything else is taken out. If the amount received most recently is higher or lower than usual, write instead that personÕs usual income. Note: If you are in the Military Housing Privatization Initiative, do not include this housing allowance.
  3. NO INCOME: Check the box if the person has no income.

Part 6- RACIAL/ETHNIC IDENTITY: Put a check mark next to the racial/ethnic group of your child. This information helps us to be sure everyone gets benefits on a fair basis. You do not have to answer this question to get free or reduced meals.

Part 7 - SIGNATURE: An adult household member must sign the application or it cannot be approved. The social security number of the adult signer must be included unless otherwise noted. If the adult household member signing the application does not have a social security number, check the box ÒNo Social Security Number.Ó Reminder: A social security number is not needed if you have listed a Food Stamp Client Number, TFA Client Number or if the children are foster children.

 


INCOME TO REPORT

                  Earnings from Work                                    Pensions/Retirement/Social Security                            Other Income

                  Wages/salaries/tips                                   Pensions                                                                         Earnings from second job

                  Strike benefits                                              Retirement income                                                        Disability benefits

                  Unemployment compensation                   Social Security                                                               Interest/dividends

                  WorkmenÕs compensation                        Veteran payments                                                          Cash withdrawn from savings

                  Net income from self-owned                   Supplemental Security income                                       Income from Estates/Trust/Investments

business or farm                                                                                                                                   Regular Contributions from persons not living in the                                                                                                                                                                                      household

Child Support/Alimony                                                                                                             Royalties/Annuities/Rental Income

                  Alimony payments                                                                                                                                 Any other monies that may be available to pay for the

                  Child Support payments                                                                                                                           childÕs meals or milk

 

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 of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (800) 795-3272 or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.