If your household gets FOODSHARE, FDPIR, OR W-2 CASH BENEFITS, follow these instructions:

Part 1: List child(ren)’s name, school, grade, and a FoodShare, W-2 cash benefits, or Food Distribution Program on Indian Reservations (FDPIR) 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.

For Public Schools Only

If you are applying for a child that is HOMELESS, MIGRANT or a RUNAWAY, follow these instructions:

Check the appropriate box in Part 2 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, pensions, (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.

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

FoodShare, W-2 Cash Benefits or Food Distribution Program on Indian Reservations (FDPIR) case # (if any). Skip to Part 5 if you list one of the above.

Case #

Case #

Case #

Case #

Case #

DO NOT LIST: Forward or Quest Card numbers; or Medicaid, SSI, W-2 Childcare case numbers. Please fill in Part 4 if you are not receiving FoodShare, W-2 cash benefits or Food Distribution Program on Indian Reservations (FDPIR) benefits at this time.

Part 2.  Homeless/Migrant/Runaway  (For Public Schools Only)

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                 

1.

$______/________

$______/________

$______/________

$______/_______

q                 

2.

$______/________

$______/________

$______/________

$______/_______

q                 

3.

$______/________

$______/________

$______/________

$______/_______

q                 

4.

$______/________

$______/________

$______/________

$______/_______

q                 

5.

$______/________

$______/________

$______/________

$______/_______

q                 

6.

$______/________

$______/________

$______/________

$______/_______

q                 

7.

$______/________

$______/________

$______/________

$______/_______

q                 

8.

$______/________

$______/________

$______/________

$______/_______

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.)

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: _______ Verifying Official’s Signature: __________________ Date: ______