|STEP 1: LIST ALL HOUSEHOLD MEMBERS WHO ARE INFANTS, CHILDREN, AND STUDENTS UP TO AND INCLUDING GRADE 12|
|Tell us how many infants, children, and school students live in your household. They do NOT have to be related to you to be a part of your household.
Who should I list here? When filling out this section, please include ALL members in your household who are:
|A) List each child’s name.Print each child’s name. Use one line of the application for each child. When printing names, write one letter in each box. Stop if you run out of space. If there are more children present than lines on the application, attach a second piece of paper with all required information for the additional children.||B) Is the child a student at [name of school/school system here]? Mark ‘Yes’ or ‘No’ under the column titled “Student” to tell us which children attend [name of school/school district here]. If you marked ‘Yes,’ write the grade level of the student in the ‘Grade’ column to the right.||C) Do you have any foster children? If any children listed are foster children, mark the “Foster Child” box next to the child’s name. If you are ONLY applying for foster children, after finishing STEP 1, go to STEP 4.
Foster children who live with you may count as members of your household and should be listed on your application. If you are applying for both foster and non-foster children, go to step 3.
|D) Are any children homeless, migrant, or runaway? If you believe any child listed in this section meets this description, mark the “Homeless, Migrant, Runaway” box next to the child’s name and complete all steps of the application.|
PLEASE USE A PEN (NOT A PENCIL) WHEN FILLING OUT THE APPLICATION AND DO YOUR BEST TO PRINT CLEARLY.
|STEP 2: DO ANY HOUSEHOLD MEMBERS CURRENTLY PARTICIPATE IN SNAP, TANF, OR FDPIR?|
|If anyone in your household (including you) currently participates in one or more of the assistance programs listed below, your children are eligible for free school meals:
|A) If no one in your household participates in any of the above listed programs:
||B) If anyone in your household participates in any of the above listed programs:
|STEP 3: REPORT INCOME FOR ALL HOUSEHOLD MEMBERS|
|How do I report my income?
|3.A. REPORT INCOME EARNED BY CHILDREN|
|A) Report all income earned or received by children. Report the combined gross income for ALL children listed in STEP 1 in your household in the box marked “Child Income.” Only count foster children’s income if you are applying for them together with the rest of your household.
What is Child Income?Child income is money received from outside your household that is paid DIRECTLY to your children. Many households do not have any child income.
|3.B REPORT INCOME EARNED BY ADULTS|
|Who should I list here?
|B) List adult household members’ names. Print the name of each household member in the boxes marked “Names of Adult Household Members (First and Last).” Do not list any household members you listed in STEP 1. If a child listed in STEP 1 has income, follow the instructions in STEP 3, part A.||C) Report earnings from work. Report all income from work in the “Earnings from Work” field on the application. This is usually the money received from working at jobs. If you are a self-employed business or farm owner, you will report your net income.
What if I am self-employed? Report income from that work as a net amount. This is calculated by subtracting the total operating expenses of your business from its gross receipts or revenue.
|D) Report income from public assistance/child support/alimony. Report all income that applies in the “Public Assistance/Child Support/Alimony” field on the application. Do not report the cash value of any public assistance benefits NOT listed on the chart. If income is received from child support or alimony, only report court-ordered payments. Informal but regular payments should be reported as “other” income in the next part.|
|E) Report income from pensions/retirement/all other income. Report all income that applies in the “Pensions/Retirement/ All Other Income” field on the application.||F) Report total household size. Enter the total number of household members in the field “Total Household Members (Children and Adults).” This number MUST be equal to the number of household members listed in STEP 1 and STEP 3. If there are any members of your household that you have not listed on the application, go back and add them. It is very important to list all household members, as the size of your household affects your eligibility for free and reduced price meals.||G) Provide the last four digits of your Social Security Number. An adult household member must enter the last four digits of their Social Security Number in the space provided. You are eligible to apply for benefits even if you do not have a Social Security Number. If no adult household members have a Social Security Number, leave this space blank and mark the box to the right labeled “Check if no SSN.”|
|STEP 4: CONTACT INFORMATION AND ADULT SIGNATURE|
|All applications must be signed by an adult member of the household. By signing the application, that household member is promising that all information has been truthfully and completely reported. Before completing this section, please also make sure you have read the privacy and civil rights statements on the back of the application.|
|A) Provide your contact information. Write your current address in the fields provided if this information is available. If you have no permanent address, this does not make your children ineligible for free or reduced price school meals. Sharing a phone number, email address, or both is optional, but helps us reach you quickly if we need to contact you.||B) Print and sign your name and write today’s date. Print the name of the adult signing the application and that person signs in the box “Signature of adult.”||C) Mail Completed Form to: Insert School/District address here||D) Share children’s racial and ethnic identities (optional). On the back of the application, we ask you to share information about your children’s race and ethnicity. This field is optional and does not affect your children’s eligibility for free or reduced price school meals.|