Schoo! Year 2019-2020 ‘The Nevada City Schoo! Distt participates in the National School Lunch Prouram by olin nutriious meas ever school da, Students may buy lunch for $2.50. Elle students may recive meas ree of charge or atthe reduced-price rate of $0.40 for lunch, You or your ehlden donot have tobe US. citizens to quai or ree or educed- price meals, Ithere are more household members than the number of ines onthe application, attach a Second application Effective July 1, 2019-hine 30, 2020 Household “wie Per Every Two Sime Year Month Month Weeks 1 $2107 Stee $9698 ODS aS 2 sigs e074 tak a sos 92801651588 4 a a 5 seers 4682 ae? 17 6 sao 5550 2e87 ase 7 a a 8 ws eat o st or ech actions amity member, a Sei $a Sai Sais 8 18 ‘QUALIFICATION: Your children may qualify for fee or reduced-price meals if your househols income falls ao below the federal Income Egoity Guidelines below. APPLYING FOR BENEFITS: An application for re or reduced: price meals ‘cannot be reviewes unless all required fields are complete. & household ‘may apply at anytime during the school year you are not eligible now, ‘but your household income decreases, househald sie increaes, or CET ee STEP 4: STUDENT INFORMATION Include ALL STUDENTS who attend Nevada City Schoo Distr. Print theiename st, mide nafs), schoo, grade lve, and bate any student Este foster ch ET ‘household member becomes eigible or ClFresh alforna Wark Opportunity and Responsibly to Kids (CAIWORKS),or Food Distribution Program oa Inaian Reservations (FOP) benefit, you may submit an application at ent te. DIRECT CERTIFICATION: An application not required ite housshols| receives a notifation letter indeatng ll hldren are automaticaly corti for ree meas you di not receive ater, please complete an application, VERIFICATION: Schoo! officials may check the information onthe pplication at any tne during the School year You may be asked to| Submit information to vatidate your ncome a careat bit for Cares, CalWORKs, r FPIR benefits WIC PARTICIPANTS: Households that recive Spcial Supplemental Nuaition Program for Women, Infants, and Cran (WIE) Benefits, may be eliible for ree or reduced-price meals by completing an application. HOMELESS, MIGRANT, RUNAWAY & HEAD START: Children who meet the dentin of homeless, migrant, or runaway and cron paticpating in their choos Head Stat prosram are eligible for ree ‘meals Please contact school oficial for assistance t (530) 265-182, FOSTER CHILO: The egal responsiblity must be through a foster eare ‘agency or court to qualify for fee meal foster child may be included {3a household member he foster family chocses to appy for ther rnon-ostrchiléren on the same application and must report ny personal income eaened by the foster chil the non-fostr enon remot elisbe, this doesnot prevent a foster cid from receiving fee FAIR HEARING: I'you donot agree uit the schoa's decision regarding ‘your application's determination or the result of veication, you may ‘iscuss it withthe hearing fica You alo have the ight to a ai hearing, which maybe equestea by eaing or weting the flung Paige Moore, 800 Hoover ln, Nevada Cty, CA35859, (530) 265-1821. ELIGIBILITY GARRVOVER: Your chi’ lity satus fem the previous Stool yar wil continue into the neve shool yer for up to 20 operating daysoruntla new determination made, When te earryver period fends, your child wl be charged the ful price for meas, unless the household receives notfcation letter for fee or reduced price meas School offical are not required to send reminder or expr clgibity NON. DISCRIMINATION STATEMENT In accordance with Federal chil rights aw and US. Department of Agriculture (USOA) i rights regulations an pokes, the USDA, ts Agancies, office, and employees, and institutions participating in or adranstering USDA programs are Prohibited from discriminating based on race coor, ational orn, 2% ‘tabi, 2g, orreprel or retaliation for prior cv ight actly many program or actwity conducted o funded by USDA Petsons with abies oho requ alternative means of communication {or program information eg ral, lrg pit, auciatape, amenican Sign Language, ete), sould contact the Agency (state or local) where they applied for benefits Individual who are dea hard ef hearing or have Speech disabilities may contact USDA tough the Federal Relay Service at (00) 877-8338. tddionly, program information may be made avalable ‘languages other than Enh Tofileaprosram complaint of discrimination, complete the USOA rogram Discrimination Complaint Form, (AD 3027) found online at: itp aserusdagov/comaint ling cust. hte and at any USOA ofc, or wite a eter addressed to USDA and provide inthe eter allot the information requested the form. To request copy ofthe complaint focm, eal(856) 632.9952 Sunt your completed form orleter to USDA by: (2) Mai US. Department of Agriculture, Office of the Assistant Secretary for Ci Rights, 1400 Independence Ave SW, Washington, 202509410; (2) Fax: (202) 660-7482; 0¢ (8) €-mal progam intake usta gov. Tisinsteuton san equal opportunty provider. Foster” box. you are only applying for fester ch, complete STEP 1, and then continue to STEP 4. Hany student listed may be homeless, migrant, or runaway, check the aplcable “Homeless, Migrant, or Runawaybox and complete all STEPS ofthe application, ‘STEP 2: ASSISTANCE PROGRAMS ~ If ANY household member (chi or adult participates in CalFresh, CalWORKs, oF FDPIR, thenal chidren are egle for fre meals, Must check the applicable assistance program Box, enter one ‘ase number, and then continue to STEP 4. fo one participates, ship STEP 2 nd continue ta STEP 3 ‘STEP 3: REPORT INCOME FOR ALL HOUSEHOLD MEMBERS ~ Must report GROSS Income (before deductions) from ALL heuseho! members (children and adult) in whole dollars. Enter “0” for any household member tat does not Al Report the combined GROSS income forall tudens listed in STEP 1 and enter the appropiate pay period. Incude a ose chi’ income i you ace apphing or foster and non foster chikren onthe same appcaton 8) Print the nares frst an lst) of ALL OTHER Household members net stein TEP 1, including youre, Repor the tol GROSS income fram each source and enter the appropriate pay prio. (©) Enter the total household size (ehldren and adult). Ths number MUST equal the listed household members from STEP 1 and STEP 2. | Enter the Inst four digits of your Social Security number (SS). no adult household member hasa SSN, check the “NO SN" box STEP 4: CONTACT INFORMATION & ADULT SIGNATURE ~The application must be signed by an adult household member. Print he name of the adult signing the application, contac iaormation and ody’ date (OPTIONAL: CHILDREN’S ETHNIC AND RACIAL IDENTITIES ~ This fll is ptional to complete and doesnot afet your chikre’selblity fries or reduced-price meals. Please check the approprite boxes INFORMATION STATEMENT: The ichrd 8. Russll National School Lunch Aet requires the information on this application. You 4a nat have ta ge the information, but you do ao, we cannot approve your chi for fre or reduced-price meals. You must include the last four digits f the socal secuty numberof the adult houschal member who sigue the appleation. The lat four dts ofthe social secunty number are not required when you Is | CalFesh, CalWORKs, or FDPIR case number or other FDA identifier for your child or when you indicate that the adult householf member signing the pplication doesnot have» socal secur number. We will use you" Information to determine your child is eligible for fee or reduced-price meals, and for administration and enforcement ofthe unch and breakfast programs [QUESTIONS/NEED ASSISTANCE: Please contact Jen Packt (530) 265 1823. ‘SUBMIT: Please submit a complete application to your chit schoo or the nutrition office 3t 800 Hoover Ln, Nevada Cty, CA 95958. You wl be notified if your application i proved or denied fr fee or reduce price mealston ep tein a8? ‘Schoo! Year 2019-2020 Nevada City School District Application for Free and Reduced-Price Meals complete one application per household. Please ead the instructions on how to apply Print clearly with a pen. This institution isan equal opportunity provider. California Education Code Section 495572): Applications for free and reduced-price meals may be submitted at anytime during a school day. Children participating inthe fe {Lunch Program will nt be overtly identified by the use of special tokens, special tickets, special serving lines, separate entrances, separate dining areas, or by any other means. STEP 1~ STUDENT INFORMATION _civen in Foster Care and chidren who meet the definition of Homeles 31 National Schoo! Migrant, Runaway ae eligible for ree mea Prin the name of €ACH STUDENT Enter school name and ‘heck the appcabie box Whe Hudent (Fst ident, Last) grade level {euter, homeless, migrant, oF runaway. TEXAMPLE: Joseph P Adams EXAMPLE: Lincoln Elementary ast Foster—[ Homeless [Migrant [Runaway o a o a o a o ‘STEP 2 ~ ASSISTANCE PROGRAMS: Calfresh, CalWORKs, or FDPIR ‘00 ANY household members child or adult currently participate in CalFresh, CaIWORK or FDPIR? NO, sip STEP 2 and continue to STEP. ives, check the applicable program box enter one cae | Select Program Type! “ter Care Number nur, skip STEP 3, and continue to STEP 4 Deattresh Cleawonns C1 rome STEP 3 REPORT INCOME FOR ALL HOUSEHOLD MEMBERS (Skip this step if you answered "YES' in STEP 2) [A. STUDENT INCOME: Sometimes stodentsn the household ean income. Enter the TOTAL GROSS income (before ces neice te eugene tae immerncitmreentn ee ew [STEP 4 CONTACT INFORMATION & ADULT SIGNATURE. Certicaton: | cet (promise) that alnformation on this application itive and that all ncome is reported. lunderstand ‘that this informaton is gen in connection withthe receipt of {federal funds, and that school official may very check the Information, lam aware that if purposly give fase information, my children may lse meal benefits, 2nd may be prosecued under applicable state and federal laws ‘Signature of ult completing this application Total student income [Wow Often] loften” box: W= Weekly, 2W = Biweekly, 2M = Twice a Month, M= Monthly, fs. au OTieR HOUSEHOLD MEMBERS (including youself Ust ALL household members not sted n STEP I, even they do ot recalve Income. For each household mernber, report the TOTAL GROSS income (before deductions) n whole dallas foreach source Ith household member doesnot receive income from any sources, write 0”. you enter "0" or leave any feds blank, you are certlving (promising) tht there sno income to report. Pant Name! leer the appropriate pay period inthe "How Often” box: W = Weakly, 2W = Ghweekiy, 2M = Twice a Month, M = Monthy, Y= Yearly Prin the name of ALL OTHER HousehoW Members Tc urscemwog | Hom | Puble Asisance/SSY/ [How | PensonRatremend [How | ba ARNE est and ast) ines rom Work | often | chia supporv/Almory |onen | allother Income | Often _ Waling Adres k otal Household Members Enter he fast four digits of Social Security number (SSN) from Check the box (Children and Adults) the Primary Wage Eamer or Other Adult Household Member nossw 0 'DO NOT COMPLETE. SCHOOL USE ONLY = ‘OPTIONAL ~ CHILDREN'S ETHNIC AND RACIALIDENTITIES [How Often? Cl Weekly C1 6i-Weekly CI Twice a Month C Monthly (I Yearly Feta! Household tncer ‘We are required to ask for information about your children’s race and ethnicity, This. [annual nome Conver: Westy 52, wee x26, Twice a Monthx24, Monthy? __|[$ information important and els to mae sue we re ful serving ou community. Total Household Se | egy Status free Cl Reducedpice Pid (Oened) | © Caegoral Responding to ths selon opvonl and doesnot fet our chen eit for {revo reduced-price mele. [1] [Weried ss: Homeless Cinigrant (Runaway error Prone Ethnic (check one}: [Determining Orcas Signature: ate: C1 Hispanic or tatino not Hispanic or tatino | ontrming OFFars Snatare Date ac (check ne or mor: D1 American indian or Alaskan Native [1 Asin 1 Black or African American riving OF cas Seratore: te nati Hawatan or other Paci ander D woe