FREE AND REDUCED PRICE SCHOOL MEALS FAMILY APPLICATION PARTI. CHILDREN Part 2, BENEFITS ‘Names of ali children ‘School —— ‘Student ID or Check if [Check | List SNAP, TANF, or FDPIR (First, Middle itil, Grade Foster | ifNO | case #for child household last) Child | income | member (i any). Skipto Part S ifyoulista case & a; oO _ | - a, o alae ——| Q Q ~ _ ao; oO _ a a “| PART 2. BENEFITS if any member of your hougehoid receives SNAP, TANF, or FDPIR other than those listed above provide the name and case # for the person who receives benefits and skip to part 5. If no one receives these benefits, skip to Part 3. NAME: CASE NUMBER, = PART 3.if any child you are applying for is HOMELESS, MIGRANT, or a RUNAWAY check the appropriate box HOMELESS G MIGRANTQ RUNAWAY 1 PART 4, TOTAL HOUSEHOLD GROSS INCOME (LIST ALL OTHER FAMILY MEMBERS, INCLUDING CHILDREN WITH INCOME) CNAME 2. HOW MUCH AND HOW OFTEN IT WAS RECEIVED (Check [Earnings From Work | Welfare, cild support, [ Pensions, retirement Socal [AI Other Tacome NO [before deductions alimony Security, S81, VA benefits income [How Often [Income — [How Often |Income ow Often fincome [How Often oF 5 F g ol is s g r of G F is of F G F ol F iy F PARTS, SUGNATURE AND LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (ADULT MUSTSTGN) “An adult household member must sign the application. i Part 4 is completed, the adult signing the form also must it the last four digits of 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 ofthis page.) Icertiy (promise) that all nformetion on this application is true and that ollincame is reported. understand cha the choo! will get Federal funds based on the information f lve. understand that school octal may verify (check) te information. understand that purposely give false Information, my children may lose meal bent, ‘and Imay be prosecuted Sign here: Print name. Date: Address: Phone Number: Gity:__ ‘State: Zip Code: Last four digits of Social Security Number. ***-" "= PART 6. CHILDREN'S ETHNIC AND RACIAL IDENTITIES (OPTIONAL) [Ghoase one ethnic: Choose one or more (regardles of echizip)= not have a Social Security Number QHispanic/Latino —|C1Asian —-_CLAmeriean Indian or Alaska Native O Black or African American JG.Not Hispanic/Latino | White __C\Native Hawaiian or other Pacific slander Se Heme ant | ‘Annual Income Conversion: Weekly x 52, Every 2 Weeks x26, Twice A Month x24 Monthly x12 —____Totalincome:__Per: 1 Week, (Every 2 Weeks, C Twice A Month, C1 Month, C1 Year* Income Eligibility: Free Reduced Error Prone___ (document for errr-prone/focused verification methods only) Directly Certified Free: DCA SNAP pensar al sowes) Direct Cert TANF/FOPIR/Homeless/Migrant/Runaway/Foster/Administrative categorically Free (notin DCA): SNAP Letter but not Direct Cert____Categoricaly Free Case # on Application but not Direct Cert__ Denied___Reason: Date Voluntarily Withdrawn: Determining Official’s Signatur Date: 2 it (verification only) Date: (verification only)