• Free and Reduced Lunch Application

    Free and Reduced Lunch Application

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  • List all household member names (children and adults).  This includes anyone living with you who shares resources, even if not related.

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  • 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 
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    • 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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