Free-and-Reduced Lunch Application

Free and Reduced Lunch Application
Student Name *

First Name Last Name
Parent (Applicant) Name *

First Name Last Name
Last Four Digits of Social Security Number of Parent/Adult Applicant *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number
All families, including those direct certified, those that receive assistance from other programs (SNAP, TANF, etc.) or those that are applying based on income eligibility must submit the two most recent pay stubs and/or documentation of all other income for each adult within the household. If the family has a direct certification letter from the previous school, this documentation could also be used to verify. This application is not complete until the below form is submitted and the required pay stubs/documentation are submitted to the school. Students will be served lunch without supporting documentation for one month, after which, if documentation is not received, the student's lunch account will change to full-pay status. *

I understand the above requirement and that documentation is required to complete this application.
Do any of the household members utilize assistance programs (SNAP, TANF, etc.)? *

Yes No
Choose (or specify) the assistance program

SNAP TANF FDPIR
Please provide a case/reference/account number.
Skip question if household members do not utilize assistance programs
List all household member names (children and adults). This includes anyone living with you who shares resources, even if not related.

Enter the names and ages of all household members *

	First Name	Last Name	Age
Household Member 1
Household Member 2
Household Member 3
Household Member 4
Household Member 5
Household Member 6
Household Member 7
Household Member 8
Household Member 9
Household Member 10

The section below is required for families to submit documented income from all sources. You DO NOT have to fill in each space in the grid; instead, find the spaces that apply to the type(s) of income received by the adult member corresponding to when that adult receives that income (weekly, bi-weekly, etc.). Documentation provided should match the amounts entered in this section.

For example, if an adult receives child support on a monthly basis, follow the Child Support row over to the cell under the Monthly column, and fill in the amount received in the corresponding box.

Do this for all income sources and for each separate adult in the household.

Income Guidance
Guidance

Sources of Income for Children

- Earnings from work
- Social Security
- Disability Payments
- Survivor’s Beneﬁts
- Income from person outside the household
- Income from any other source

Sources of Income for Adults

Earnings from work

- Salary, wages, cash bonuses
- Net income from self- employment (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

Public Assistance/Alimony/Child Support

- 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

Pensions/Retirement/All Other Income

- 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

Income Report for Household Members
Name - Child 1 (if child provides income)

First Name Last Name

Income Amount and Frequency - Child 1 (if child provides income)

	Weekly	Bi-Weekly	2x Per Month	Monthly
Work Income

Name - Adult 1 (required) *

First Name Last Name

Income Sources, Amounts, and Frequency - Adult 1 *

	Weekly	Bi-Weekly	2x Per Month	Monthly
Work Income
Public/State Assistance
Alimony
Child Support
Retirement
Pension
Other

Name - Adult 2 (if applicable)

First Name Last Name

Income Sources, Amounts, and Frequency - Adult 2 (if applicable)

	Weekly	Bi-Weekly	2x Per Month	Monthly
Work Income
Public/State Assistance
Alimony
Child Support
Retirement
Pension
Other

Name - Adult 3 (if applicable)

First Name Last Name

Income Sources, Amounts, and Frequency - Adult 3 (if applicable)

	Weekly	Bi-Weekly	2x Per Month	Monthly
Work Income
Public/State Assistance
Alimony
Child Support
Retirement
Pension
Other

Name - Adult 4 (if applicable)

First Name Last Name

Income Sources, Amounts, and Frequency - Adult 4 (if applicable)

	Weekly	Bi-Weekly	2x Per Month	Monthly
Work Income
Public/State Assistance
Alimony
Child Support
Retirement
Pension
Other

Ethnicity (check one) *

Hispanic or Latino Not Hispanic or Latino
Race (check all that apply) *

American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White
The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identiﬁer for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. 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 look into violations of program rules.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for beneﬁts. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To ﬁle a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_ﬁling_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410
fax: (202) 690-7442; or
email: program.intake@usda.gov.
This institution is an equal opportunity provider.
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Free and Reduced Lunch Application