INSTRUCTIONS for completing the Free and Reduced-Price Meal Application
IF ANY MEMBER OF YOUR HOUSEHOLD RECEIVES FOOD ASSISTANCE PROGRAM (FAP/SNAP) OR TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) BENEFITS, FOLLOW THESE INSTRUCTIONS: STEP 1: List all children age 18 and under that are supported with the household’s income, even if they are not related to you. Be sure to include the
child listed at the top of the form. If there is not enough space to list all children, use a second form and attach the forms together. List the date of birth of each child. In the next three
columns, circle Yes or No to answer each question for each child listed. STEP 2: Enter either the FAP/SNAP or TANF case number in the designated space. The case number will be on
your letter of eligibility; it is not the number on your EBT card. STEP 3: Skip this step. STEP 4: Skip this step. STEP 5: Enter your address and phone # (if available). An adult household
member must sign the form. Print the name of the person who signed the form, then enter the date signed.
IF YOU ARE APPLYING FOR A FOSTER CHILD, FOLLOW THESE INSTRUCTIONS: With appropriate documentation, foster children are automatically eligible for free meals regardless
of the income of the household where they reside. You have the option to provide the child care center with official documentation from the foster care agency or court that placed the child
in the household, rather than completing this application. Should you choose to complete this application, and you are applying only for a foster child(ren), then only complete STEPS 1 and
5. If you are applying for foster and non-foster children, complete STEPS 1, 3, 4 and 5. If completing STEP 3, do not include payments to the household for the care of the foster child(ren).
See the instructions listed below for the applicable steps.
ALL OTHER HOUSEHOLDS, FOLLOW THESE INSTRUCTIONS: STEP 1: List all children age 18 and under that are supported with the household’s income, even if they are not related
to you. Be sure to include the child listed at the top of the form. If there is not enough space to list all children, use a second form and attach the forms together. List the date of birth of each
child. In the next three columns, circle Yes or No to answer each question for each child listed. STEP 2: Skip this step. STEP 3: Enter the total income received by all children listed in
STEP 1, then check how often the income is received. STEP 4: List all adults age 19 and older that are supported with the household’s income, even if they are not related to you and even
if they receive no income. If there is not enough space to list all adults, use a second form and attach the forms together. For each adult, list the amount of income he/she regularly receives
before taxes or anything else is taken out and circle how often the income is received (frequency) in the appropriate columns. If self-employed, list net income. See examples below for
sources of income to report. For any adult with no income, write “none” or “0.” Any income fields that are blank will also be counted as a zero (0). Enter the total number of household
members (all children and adults), then list the last four digits of the social security number (SSN) of the adult completing/signing the application (or write NONE if he/she has no SSN).
STEP 5: Enter your address and phone # (if available). An adult household member must sign the form. Print the name of the person who signed the form, then enter the date signed.
Sources of Income for Children
Earnings from work |
A child has a regular full or part-time job where they earn a salary or wages |
Social Security
- Disability Payments
- Survivor’s Benefits
|
- A child is blind or disabled and receives Social
Security benefits
- A parent is disabled, retired, or deceased, and
their child receives Social Security benefits
|
Income from person
outside the household |
A friend or extended family member
regularly gives a child spending money |
Income from any
other source |
A child receives regular income from a
private pension fund, annuity, or trust |
Sources of Income for Adults
Earnings from Work |
Public Assistance/ Alimony/Child Support |
Pensions/Retirement/All Other Income |
- Salary, wages, cash
bonuses
- Net income from selfemployment (farm or business)
If you are in the U.S. Military:
- Basic pay and cash bonuses (do
NOT include combat pay, FSSA or
privatized housing allowances)
- Allowances for off-base housing, food
and clothing
|
- Unemployment benefits
- Worker’s compensation
- Supplemental Security
Income (SSI)
- Cash assistance from
State or local government
- Alimony payments
- Child support payments
- Veteran’s benefits
- Strike benefits
|
- Social Security (including railroad
retirement and black lung benefits)
- Private pensions or disability
benefits
- Regular income from trusts or estates
- Annuities
- Investment income
- Earned interest
- Rental income
- Regular cash payments from outside
household
; |
The Richard B. Russell National School Lunch Act requires that, unless you list a current Food Assistance Program (FAP/SNAP) or Temporary Assistance for Needy Families (TANF) case
number or are applying for a foster child, you must include the last four digits of the Social Security Number (SSN) of the adult household member signing the application or indicate that the
signer does not have a SSN. Providing the last four digits of a SSN is not mandatory, but if this information is not given or an indication is not made that the signer does not have a SSN, the
application cannot be approved. The information provided on this form may be verified through program reviews, audits, and investigations and may include contacting employers to
determine income, contacting a welfare office to verify receipt of FAP/SNAP or TANF benefits, contacting the state employment security office to determine the amount of benefits received,
and checking any documentation produced by the household to prove the amount of income received. These verification efforts may result in a loss or reduction of benefits, administrative
claims, or legal actions if incorrect information is reported. 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 investigate violations of program rules.
This institution is an equal opportunity provider. Please refer to the accompanying Parent Letter to read the full Nondiscrimination Statement