GREENWICH PUBLIC SCHOOLS PARENT/GUARDIAN LETTER TO HOUSEHOLDS FOR SCHOOL MEALS AND SNACKS

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1 GREENWICH PUBLIC SCHOOLS PARENT/GUARDIAN LETTER TO HOUSEHOLDS FOR SCHOOL MEALS AND SNACKS Dear Parent/Guardian: Children need healthy meals to learn. Greenwich Public Schools offers healthy meals every school day. Children may buy lunch for $3.25 for elementary schools, $3.40 for middle schools, $3.50 for high school and breakfast for $1.60- $2.10 at participating schools. Your children may qualify for free meals or for reduced price meals. Reduced price is $0.30 for breakfast and $0.40 for lunch. This packet includes an application for free or reduced price meal benefits, and a set of detailed instructions. Below are some common questions and answers to help you with the application process. Note: Children receiving Supplemental Nutrition Assistance Program (SNAP) or Temporary Family Assistance (TFA) benefits may be directly certified and automatically eligible for free meals without further applying for benefits. Questions regarding SNAP/TFA and direct certification should be sent to: John Hopkins If you have received a NOTICE OF DIRECT CERTIFICATION for free meals, do not complete the application. However, do let the school know if any children in your household are not listed on the Notice of Direct Certification letter you received. 1. WHO CAN GET FREE OR REDUCED PRICE MEALS? All children in households receiving SNAP or TF A benefits from are eligible for free meals. Foster children that are under the legal responsibility of a foster care agency or court are eligible for free meals. Children participating in their school's Head Start program are eligible for free meals. Children who meet the definition of homeless or runaway are eligible for free meals. Children may receive free or reduced price meals if your household's income is within the limits on the Federal Income Eligibility Guidelines. Your children may qualify for free or reduced price meals if your household income falls at or below the limits on this chart: I I REDUCED FEDERAL ELIGIBILITY INCOME CHART Effective 7/ to 6/30/2016 Household size Yearly Monthly Weekly 1 21,775 1, ,471 2, ,167 3, ,863 3, ,559 4,380 1, ,255 5,022 1, ,951 5,663 1, ,647 6,304 1,455 Each additional person: +7, HOW DO I KNOW IF MY CHILDREN QUALIFY AS HOMELESS OR RUNAWAY? Do the members of your household lack a permanent address? Are you staying together in a shelter, hotel, or other temporary housing arrangement? Does your family relocate on a seasonal basis? Are any children living with you who have chosen to leave their prior family or household? If you believe children in your household meet these descriptions and haven't been told your children will get free meals, please call or Denise Qualey to see if they qualify at: (203) or dqualey@kidsincrisis.org. 3. DO I NEED TO FILL OUT AN APPLICATION FOR EACH CHILD? No. Use one Free and Reduced Price School Meals Application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to your school's office. 4. SHOULD I FILL OUT AN APPLICATION IF I RECEIVED A LETTER THIS SCHOOL YEAR SAYING MY CHILDREN ARE ALREADY APPROVED FOR FREE MEALS? No, but please read the letter you got carefully and follow the instructions. If any children in your household were missing from your eligibility notification, contact the Food Service Office at: or john_hopkins@greenwich.kl2.ct.us immediately.

2 5. MY CHILD'S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT A NEW ONE? Yes. Your child's application is only good for that school year and for the first few days of this school year. You must send in a new application unless the school told you that your child is eligible for the new school year. 6. I GET WIC. CAN MY CHILDREN GET FREE MEALS? Children in households participating in WIC may be eligible for free or reduced price meals. Please send in an application. 7. WILL THE INFORMATION I GIVE BE CHECKED? Yes. We may also ask you to send written proof of the household income you report. 8. IF I DON'T QUALIFY NOW, MAY I APPLY LATER? Yes, you may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free and reduced price meals if the household income drops below the income limit. 9. WHAT IF I DISAGREE WITH THE SCHOOL'S DECISION ABOUT MY APPLICATION? You should talk to school officials. You also may ask for a hearing by calling or writing to: Vicki Gregg, Food Service Manager, , 290 Greenwich Ave. Greenwich, CT MAY I APPLY IF SOMEONE IN MY HOUSEHOLD IS NOT A U.S. CITIZEN? Yes. You, your children, or other household members do not have to be U.S. citizens to apply for free or reduced price meals. 11. WHAT IF MY INCOME IS NOTAL WAYS THE SAME? List the amount that you normally receive. For example, if you normally make $1000 each month, but you missed some work last month and only made $900, put down that you made $1000 per month. If you normally get overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income. 12. WHAT IF SOME HOUSEHOLD MEMBERS HAVE NO INCOME TO REPORT? Household members may not receive some types of income we ask you to report on the application, or may not receive income at all. Whenever this happens, please write a 0 in the field. However, if any income fields are left empty or blank, those will also be counted as zeroes. Please be careful when leaving income fields blank, as we will assume you meant to do so. 13. WE ARE IN THE MILITARY. DO WE REPORT OUR INCOME DIFFERENTLY? Your basic pay and cash bonuses must be reported as income. If you get any cash value allowances for off-base housing, food, or clothing, or receive Family Subsistence Supplemental Allowance payments, it must also be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. Any additional combat pay resulting from deployment is also excluded from income. 14. WHAT IF THERE ISN'T ENOUGH SPACE ON THE APPLICATION FOR MY FAMILY? List any additional household members on a separate piece of paper, and attach it to your application. Contact your school office to receive a second application or visit our website to down load one: MY FAMILY NEEDS MORE HELP. ARE THERE OTHER PROGRAMS WE MIGHT APPLY FOR? To find out how to apply for SNAP benefits and to contact the Department of Social Services office in your town, contact United Way's free referral number (free call, statewide). If you have other questions or need help, call SinceWL &, S. McKcc,ie, Ph.D. Superintendent of Schools July 1, 2015

3 CARTA DE LAS ESCUELAS PUBLICAS DE GREENWICH PARA PADRES Y TUTORES SOBRE LAS COMIDAS Y REFRIGERIOS ESCOLARES Estimados padre, madre o tutor: Para poder aprender, los nifios necesitan alimentarse bien. Las escuelas publicas de Greenwich ofrecen comidas saludables todos los dfas durante la escuela. Para los estudiantes de primaria el almuerzo cuesta 3,25 d6lares, 3, 40 para los estudiantes de secundaria o Middle School y 3,50 para los estudiantes de bachillerato o High School. El desayuno cuesta entre 1,60 y 2,10 d6lares en las escuelas que lo ofrecen. Es posible que sus hijos tengan derecho a recibir co midas gratuitas o a precio reducido. El precio reducido es 0,30 por el desayuno y 0,40 por el almuerzo. Con esta carta incluimos el formulario para solicitar las comidas gratuitas o a precio reducido junto con las instrucciones detalladas. A continuaci6n mostramos algunas preguntas frecuentes y sus respuestas con el objeto de ayudarles con la solicitud. Aviso: Los estudiantes que est{m recibiendo asistencia a traves del programa de Nutrici6n Suplementaria (Nutrition Assistance Program o SNAP por sus siglas en ingles) o asistencia familiar temporal (Temporary Family Assistance o TF A por sus siglas en ingles) podnin directamente ser aprobados y tener automaticamente derecho a las comidas gratuitas sin tener que solicitarlas. Las preguntas relacionadas con los programas de SNAP o TF A y Ia aprobaci6n automatica se tendr:in que dirigir a John Hopkins al Si han recibido un aviso de APROBACION AUTOMA TICA para las comidas gratuitas, no rellenen Ia solicitud pero avisen a Ia escuela si tienen mas hijos en Ia escuela y estos no aparecen listados en Ia carta que recibieron de Aprobacion Automatica 1.,;.COMO PUEDO OBTENER COMIDAS GRA TUITAS 0 A PRECIO REDUCIDO? Todos los nifios que reciben beneficios de SNAP o TF A tienen derecho a comidas gratuitas Los nifios en acogida, (Foster Children), que estill bajo la responsabilidad legal de una agencia de acogida o tribunal, tienen derecho a recibir comidas gratuitas Los nifios que participan en el programa de Head Start en su escuela tienen derecho a recibir comidas gratuitas Los nifios que se definen sin hogar o fugados tienen derecho a recibir comidas gratuitas Los nifios que vivan en un hogar donde los ingresos econ6micos se situen dentro o por debajo de los limites establecidos por las directrices federales podnin tener derecho a comidas gratuitas o a precio reducido. Consulte el gnifico que se muestra a continuaci6n para ver si sus ingresos estan dentro o por debajo del limite establecido. I GRA.FICO SOBRE LOS INGRESOS ECONOMICOS que dictan el derecho a los I beneficios. Efectivo desde ell de julio del2015 hasta e130 de junio del2016 Numero de personas Ingresos Ingresos Ingresos Semanales en el hogar familiar Anuales Mensuales , , , , ,380 1, ,022 1, ,663 1, ,304 1,455 Cada persona adiciona

4 2. L,COMO SE SI MIS HIJOS SON DEFTNIDOS COMO NINOS SIN HOGAR 0 FUGADOS? L,Carecen los miembros de su hogar de una direcci6n permanente? L,Esta viviendo con su hijo en un refugio, en un hotel o en un hogar temporal? L,Se traslada su familia de un Iugar dependiendo de las temporadas? L,Esta viviendo con algun nifio que decidi6 abandonar a su anterior familia u hogar? Si cree que los nifios de su hogar cumplen estas caracterfsticas y no le han avisado que recibiran comidas gratuitas, p6ngase en contacto por telefono o con Denise Qualey a1 (203) o qguajey:(_llkidsincrisis.org. para determinar si tienen derecho a comidas gratuitas. 3. L,NECESITO RELLENAR UNA SOLICITUD POR CADA HIJO? No. Cuando rellene Ia solicitud para recibir comidas gratuitas o a precio reducido, utilice la misma solicitud para todos los estudiantes que vivan con usted. No podremos aprobar ninguna solicitud que no este cumplimentada, por lo que rogamos asegurese que rellena toda Ia informacion requerida. Entregue Ia solicitud cumplimentada en Ia secretaria de su escuela. 4. L,TENGO QUE RELLENAR UNA SOLICITUD SI ESTE ANO RECIBI UNA CARTA ESCOLAR DICIENDO QUE MIS HIJOS HAN SIDO APROBADOS PARA RECIBIR COMIDAS GRATUITAS? No, pero lea detenidamente Ia carta que recibi6 y siga las indicaciones. Si alguno de sus hijos viviendo con usted no aparece en esa carta, p6ngase en contacto inmediatamente con el Departamento de Servicios Alimenticios al o john hopkins@greemvich.k 12.ct.us 5. LA SOLICITUD DE MI HIJO FUE APROBADA EL ANO PASADO. z,tengo QUE RELLENAR OTRA? Si. La solicitud de su hijo es valida solo para ese afio escolar y para los primeros dias de este afio escolar. Tiene que enviar una solicitud nueva a menos que Ia escuela le haya dicho que su hijo tiene derecho a recibir comidas gratuitas o a precio reducido para el nuevo afio escolar. 6. z,pueden MIS HIJOS RECIBIR CO MIDAS GRA TUIT AS SI SOY BENEFICIARIO DEL PROGRAMA WIC? Los nifios que viven en familias que se benefician del programa WIC tambien podrian tener derecho a recibir comidas gratuitas o a precio reducido. En este caso rellene y entregue Ia solicitud. 7. z,se VA A COMPROBAR LA INFORMACION QUE DE? Si. Tam bien posiblemente, le pidamos que envie pruebas por escrito de los ingresos econ6micos que declar6 en Ia solicitud. 8. z,podria PRESENTAR OTRA SOLICITUD MAS ADELANTE, EN CASO DE QUE MI SOLICITUD NO SEA APROBADA AHORA? Si. Puede solicitar en cualquier momento durante el afio escolar. Por ejemplo, los nifios cuyo padre, madre o tutor haya perdido el empleo, tal vez puedan tener derecho a recibir comidas gratuitas o a precio reducido si los ingresos familiares se situan en ellimite o por debajo del limite de los ingresos permitidos. 9. z,que SUCEDERIA SINO ESTOY DE ACUERDO CON LA DECISION DE LA ESCUELA SOBRE MI SOLICITUD? Deberia hablar con los funcionarios escolares. Tambien puede solicitar una audiencia llamando o escribiendo a Vicki Gregg, Encargada de los Servicios Alimenticios a! o 290 Greenwich Ave. Greenwich, CT z,podria RELLENAR UNA SOLICITUD AUNQUE UN MIEMBRO DE MI FAMILIA QUE VIVE CONMIGO NO SEA CIUDADANO EST ADOUNIDENSE? Sf. Ni usted ni sus hijos, ni ningun otro miembro de Ia familia tienen que ser ciudadano estadounidense para tener derecho a recibir comidas gratuitas o a precio reducido. 11. z,que SUCEDE SI MIS INGRESOS VARIAN? Declare Ia cantidad que recibe normalmente. Por ejemplo, si normalmente gana 1,000 d6lares cada mes, pero el mes pasado solo gan6 900 d6lares porque no pudo asistir a! trabajo, declare de todos modos que gana 1,000 a! mes. Si normalmente recibe pagas por horas extra, incluyalas tambien pero no las incluya si solamente hace horas extras de vez en cuando. Si perdi6 el empleo o le han reducido las horas de trabajo o el sueldo, declare el sueldo reducido. 12. z,que SUCEDE SI ALGUN MIEMBRO DE MI FAMILIA NO APORT A INGRESOS ECONOMICOS? Es posible que alglin miembro de su familia no aporte alguno de los ingresos que le pedimos que declare o ninglin ingreso en absoluto. Si esto sucede, rogamos escriba un 0 en Ia casilla correspondiente. No obstante si alguna casilla se deja en blanco, esta tambien se contara como 0. Tenga cui dado cuando deje casillas en blanco ya que asumiremos que su intenci6n es dejarla en blanco. 13. z, TENDRIAMOS QUE DECLARAR NUESTROS INGRESOS DE MANERA DIFERENTE SI PERTENECEMOS A LAS FUERZAS ARMADAS? Tiene que indicar como ingresos su salario Msico y sus pagas extras. Si esta viviendo fuera de la base

5 military recibe compensaci6n monctaria por la vivienda, cornida y ropa, o recibe pagas suplementarias llamadas en ingles Family Subsistence Supplemental Allowance, estas se tendnin que declarar. No obstante, si su vivienda es parte de la iniciativa de viviendas para militares conocida como Military Housing Privatization Initiative, no incluya la suhvcncion de vivienda como ingreso. Cualquier paga adicional producto de un despliegue en zona de combate tarnpoco formara parte de sus ingresos. 14. (,QUE SUCEDE SINO HAY ESPACIO SUFICIENTE EN LA SOLICITUD PARA LISTAR A TODOS LOS MIEMBROS DE MI FAMILIA? Anotc al resto de sus familiares en una hoja de papel aparte e incluyala con su solicitud. P6ngase en contacto con la secretaria de su escuela si necesita una segunda solicitud o visite nuestra pagina web para bajar una (,SIMI FAMILIA NECESITA MAS AYUDA EXISTEN OTROS PROGRAMAS QUE PODAMOS SOLICITAR? Para ver como solicitar beneficios del programa SNAP y para comunicarse con el Departamento de Servicios Sociales de su ciudad, llame al telefono gratuito de informacion de United Way Si tiene otras preguntas o necesita ayuda, Harne al rs1e, Superintendente de las escuelas 1 de julio del 2015

6 Greenwich Public Schools Application for Free and Reduced-price School Meals or Free Milk Complete one application per household. Please use a pen (not a pencil). Application No: STEP 1 List ALL Household Members who are infants, children, and students up to and including grade 12 (if more spaces are required for additional names, attach another sheet of paper) Definition of Household Member: Anyone who is living with you and shares income and expenses, even if not related. Children in Foster care and children who meet the definition of Homeless, Migrant or Runaway are eligible for free meals. Read How to Apply for Free and Reduced Price School Meals for more information. Student? Child s First Name MI Child s Last Name Foster Head Even Homeless or School Grade Yes No Check all that apply Start Start Runaway STEP 2 Do any Household Members (including you) currently participate in one or more of the following Assistance Programs - SNAP OR TFA: Check one: YES or NO (This does NOT include medical (HUSKY) benefits.) To quicken the approval process, it is strongly recommended that you submit proof of SNAP or TFA eligibility with this application. See instructions. If NO household member participates in SNAP or TFA, skip Step 2 and complete STEP 3. If a household member does participate in SNAP or TFA, write a SNAP OR TFA case number here and then go to STEP 4 (Do not complete STEP 3) STEP 3 Report Income for ALL Household Members (Skip this step if you wrote a SNAP or TFA Number in STEP 2) Case Number: Write only one case number in this space. Please read How to Apply for Free and Reduced Price School Meals for more information. The Sources of Income for Children section will help you with the Child Income question. The Sources of Income for Adults section will help you with the All Adult Household Members section. A. Child Income Sometimes children in the household earn income. Please include the TOTAL income earned by all Child Household Members listed in STEP 1 here. $ Child income Weekly Bi-Weekly 2x Month Monthly How often? Weekly Bi-Weekly 2x Month Monthly B. All Adult Household Members (including yourself) List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total income for each source in whole dollars only. If they do not receive income from any source, write 0. If you enter 0 or leave any fields blank, you are certifying (promising) that there is no income to report. Name of Adult Household Members (First and Last) How often? Earnings from Work Weekly Bi-Weekly 2x Month Monthly Public Assistance/ Child Support/Alimony How often? Pensions/Retirement/ All Other Income How often? Weekly Bi-Weekly 2x Month Monthly Total Household Members (Children and Adults Step 1 & Step 3) Last Four Digits of Social Security Number (SSN) of Primary Wage Earner or Other Adult Household Member X X X X X Check if no SSN STEP 4 Contact Information information and Adult adult Signature signature I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws. Street Address (if available) Apt # City State Zip Daytime Phone and (optional) Printed name of adult completing the form Signature of adult completing the form Today s date

7 OPTIONAL Children's Racial and Ethnic Identities We are required to ask for information about your children s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children s eligibility for free or reduced price meals. Ethnicity (check one): Race (check one or more): Hispanic or Latino Not Hispanic or Latino American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other 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. The U.S Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at filing cust.html, or at any USDA office, or call (866) to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C , by fax (202) or at program.intake@usda.gov. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer. For School Use Only Do Not Write Below This Line Determining Officials (DO) for the Local Education Agency MUST complete this section. Annual Income Conversion: Weekly X 52 Every 2 weeks X 26 Twice a Month X 24 Monthly X 12 (Only convert to annual income if there are different frequencies of income listed in Step 3.) Date Certified on DC List: Directly Certified Based on the State Direct Certification List SNAP/TFA Household (Reminder: The DO must confirm a handwritten SNAP/TFA number) Foster Child Head Start Confirmed Homeless or Runaway Income Household: Total household income: per Household Size: Application approved for: Free Meals Reduced-Price Meals Application Denied Date Notice Sent: Signature of Determining Official: Date:

8 Rev. 5/19/2015 Application Instructions Page 1 of 4 HOW TO APPLY FOR FREE AND REDUCED-PRICE SCHOOL MEALS Please use these instructions to help you fill out the application for free or reduced-price school meals. You only need to submit one application per household, even if your children attend more than one school in [School District]. The application must be filled out completely to certify your children for free or reduced-price school meals [or free milk if the school participates in the Special Milk Program.] Please follow these instructions in order! Each step of the instructions is the same as the steps on your application. If at any time you are not sure what to do next, please contact [school/school district contact here---phone and preferred]. PLEASE USE A PEN (NOT A PENCIL) WHEN FILLING OUT THE APPLICATION AND DO YOUR BEST TO PRINT CLEARLY. STEP 1: LIST ALL HOUSEHOLD MEMBERS WHO ARE INFANTS, CHILDREN, AND STUDENTS UP TO AND INCLUDING GRADE 12 Tell us how many infants, children, and school students live in your household. They do NOT have to be related to you to be a part of your household. Who should I list here? When filling out this section, please include all members in your household who are: Children age 18 or under and are supported with the household s income; In your care under a foster arrangement, or qualify as homeless or runaway youth; Students attending [school/school system here], regardless of age. A. List each child s name. For each child, print their first name, middle initial and last name. Use one line of the application for each child. Please print clearly. If there are more children present than lines on the application, attach a second piece of paper with all required information for the additional children. B. List the name of the school and grade (if applicable) that each child attends and check the box to confirm if the child is a student at the school. C. Do you have any foster children? If any children listed are foster children, mark the Foster Child box next to the child s name. Foster children who live with you may count as members of your household and should be listed on your application. If you are only applying for foster children, after completing STEP 1, skip to STEP 4 of the application and these instructions. D. Are any children enrolled in a federal Head Start or Even Start Program in the school system? If you believe any child listed in this section may meet this description, please mark the Head Start or Even Start box next to the child s name and complete all steps of the application. E. Are any children homeless or runaway? If you believe any child listed in this section may meet this description, please mark the Homeless or Runaway box next to the child s name and complete all steps of the application.

9 Rev. 6/5/2015 Application Instructions Page 2 of 4 STEP 2: HOUSEHOLD MEMBER PARTICIPATION IN ONE OR MORE ASSISTANCE PROGRAMS SNAP OR TFA (THIS DOES NOT INCLUDE MEDICAL OR HUSKY BENEFITS) If anyone in your household participates in the assistance programs listed below, your children are eligible for free school meals: The Supplemental Nutrition Assistance Program (SNAP) or Temporary Family Assistance (TFA) A. IF NO ONE IN YOUR HOUSEHOLD PARTICIPATES IN ANY OF THE ABOVE LISTED PROGRAMS: Skip to STEP 3 on these instructions and STEP 3 on your application. Leave STEP 2 blank. B. IF ANYONE IN YOUR HOUSEHOLD PARTICIPATES IN ANY OF THE ABOVE LISTED PROGRAMS: Check off Yes and provide a case number for SNAP or TFA. You only need to write one case number. If you participate in one of these programs and do not know your case number, contact your DSS Social Worker. Note: Do not use a HUSKY Medical Benefits Number since this number is not a SNAP or TFA case number. It is also recommended (but not required) that you submit proof of this SNAP or TFA case number when you submit the application for processing. Proof does NOT include a copy of the CONNECT card. Skip to STEP 4. STEP 3: REPORT INCOME FOR ALL HOUSEHOLD MEMBERS A. Report all income earned by children. Refer to the chart titled Sources of Income for Children in these instructions and report the combined gross income for ALL children listed in Step 1 in your household in the box marked Total Child Income. Only count foster children s income if you are applying for them together with the rest of your household. It is optional for the household to list foster children living with them as part of the household. What is Child Income? Child income is money received from outside your household that is paid directly to your children. Many households do not have any child income. Use the chart below to determine if your household has child income to report. Sources of Child Income Sources of Income for Children Examples Earnings from work A child has a job where they earn a salary or wages. Social Security o Disability Payments o 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 persons outside the household A friend or extended family member regularly gives a child spending money. Income from any other source A child receives income from a private pension fund, annuity, or trust.

10 Rev. 6/5/2015 Application Instructions Page 3 of 4 FOR EACH ADULT HOUSEHOLD MEMBER: Who should I list here? When filling out this section, please include all members in your household who are: Living with you and share income and expenses, even if not related and even if they do not receive income of their own. Do not include people who: Live with you but are not supported by your household s income and do not contribute income to your household. Children and students already listed in Step 1. How do I fill in the income amount and source? FOR EACH TYPE OF INCOME: Use the charts in this section to determine if your household has income to report. Report all amounts in gross income ONLY. Report all income in whole dollars. Do not include cents. o Gross income is the total income received before taxes or deductions. o Many people think of income as the amount they take home and not the total, gross amount. Make sure that the income you report on this application has NOT been reduced to pay for taxes, insurance premiums, or any other amounts taken from your pay. Write a 0 in any fields where there is no income to report. Any income fields left empty or blank will be counted as zeroes. If you write 0 or leave any fields blank, you are certifying (promising) that there is no income to report. If local officials have known or available information that your household income was reported incorrectly, your application will be verified for cause. Mark how often each type of income is received using the check boxes to the right of each field. Note: Income must be listed as being received either: weekly; bi-weekly; 2 X month; or monthly. Do not list income annually. B. List Adult Household member s name. Print the name of each household member in the boxes marked Names of Adult Household Members (First and Last). Do not list any household members you listed in STEP 1. If a child listed in STEP 1 has income, follow the instructions in STEP 3, part A. C. Report earnings from work. Refer to the chart titled Sources of Income for Adults in these instructions and report all income from work in the Earnings from Work field on the application. This is usually the money received from working at jobs. If you are a self-employed business or farm owner, you will report your net income. What if I am self-employed? If you are self-employed, report income from that work as a net amount. This is calculated by subtracting the total operating expenses of your business from its gross receipts or revenue. D. Report income from Public Assistance/Child Support/Alimony. Refer to the chart titled Sources of Income for Adults in these instructions and report all income that applies in the Public Assistance/Child Support/Alimony field on the application. Do not report the value of any cash value public assistance benefits NOT listed on the chart. If income is received from child support or alimony, only courtordered payments should be reported here. Informal but regular payments should be reported as other income in the next part.

11 Rev. 6/5/2015 Application Instructions Page 4 of 4 E. Report income from Pensions/Retirement/All other income. Refer to the chart titled Sources of Income for Adults in these instructions and report all income that applies in the Pensions/Retirement/All Other Income field on the application. F. Report total household size. Enter the total number of household members in the field Total Household Members (Children and Adults). This number MUST be equal to the number of household members listed in STEP 1 and STEP 3. If there are any members of your household that you have not listed on the application, go back and add them. It is very important to list all household members, as the size of your household determines your income cutoff for free and reduced-price meals or free milk. G. Provide the last four digits of your Social Security Number. The household s primary wage earner or another adult household member must enter the last four digits of their Social Security Number in the space provided. You are eligible to apply for benefits even if you do not have a Social Security Number. If no adult household members have a Social Security Number, leave this space blank and mark the box to the right labeled Check if no SS#. 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 self-employment (farm or business) Strike benefits 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 Social Security (including railroad retirement and black lung benefits) Private Pensions or disability Income from trusts or estates Annuities Investment income Earned interest Rental income Regular cash payments from outside household STEP 4: CONTACT INFORMATION AND ADULT SIGNATURE All applications must be signed by an adult member of the household. By signing the application, that household member is promising that all information has been truthfully and completely reported. Before completing this section, please also make sure you have read the privacy and civil rights statements on the back of the application. A. Provide your contact information. Write your current address in the fields provided if this information is available. If you have no permanent address, this does not make your children ineligible for free or reduced-price school meals. Sharing a phone number, address, or both is optional, but helps us reach you quickly if we need to contact you. B. Sign and print your name. Print your name in the box Printed name of adult completing the form and sign your name in the box Signature of adult completing the form. C. Write Today s Date. In the space provided, write today s date in the box. D. Share children s Racial and Ethnic Identities (optional). On the back of the application, we ask you to share information about your children s race and ethnicity. This field is optional and does not affect your children s eligibility for free or reduced-price school meals.

12 Solicitud para Comida Escolar Gratuita y de Precio Reducido del Complete una sola solicitud por hogar. Favor de usar una pluma (no lápiz). Application No: PASO 1 Haga una lista de todos los bebés, niños y estudiantes hasta el grado 12 miembros de su hogar (si requiere más espacio, agregue otra hoja) Definición de Miembro del Hogar: Cualquier persona que vive con usted y comparte ingresos y gastos, aunque no sea familia. Niños adoptivos temporales (foster) que cumplen con la definición de migrante, sin hogar, o fugitivo son elegibles para la comida gratuita. Para más información, lea Como solicitar comida escolar gratuita y de precio reducido. PASO 2 Primer Nombre del Niño IM Apellido del Niño Participa cualquier miembro de su hogar, incluyéndose a usted, en uno o más de los siguientes programas: SNAP, TANF, o FDPIR? Marque si estudiante de [DISTRICT/ SCHOOL NAME] Marque la casilla al lado del nombre del niño(a) titulada Sin Hogar, migrante, Fugitivo y complete todos os pasos de la solicitud, ofoster. Migrante, Niño Sin hogar, Foster Fugitivo SNAP TANF FDPIR NO > Complete PASO 3. SÍ > Escriba aquí el número de su caso y luego continúe con PASO 4. (No complete el PASO 3) No. de Caso: PASO 3 Declare el ingreso de todos los miembros del hogar (No responda a este paso si usted indicó Sí en el PASO 2). Escriba sólo un número de caso en este espacio. Favor de leer Cómo solicitar comida escolar gratuita o de precio reducido para más información. La sección Fuentes de ingreso para niños le ayudará responder a la pregunta sobre el Ingreso del Niño (A). La sección Fuentes de ingreso para los adultos le ayudará responder a la pregunta sobre Todos los Miembros Adultos del Hogar (B). A. Ingreso del Niño A veces los niños del hogar ganan dinero. Favor de incluir aquí el ingreso total ganado por todos los miembros del hogar listados en el PASO 1. No tiene que incluir los niños adoptivos temporales (foster). $ Ingreso del niño Con qué frecuencia? semana quincenal 2x mes 1x mes B. Todos los Miembros Adultos del Hogar (incluyéndose a usted) Haga una lista de todos los miembros del hogar no listados en el PASO 1 (incluyéndose a Ud.) sin importar si reciben o no ingresos. Para cada miembro del hogar en la lista que recibe un ingreso, anote el ingreso total de cada fuente en dólares redondeados. Si no reciben ingresos de ninguna fuente, escribe 0. Si usted pone 0 o deja en blanco cualquier espacio, usted certifica (jura) que no hay ingresos. Con qué frecuencia? Nombres y apellidos de los adultos del hogar Ingresos semana quincenal 2x mes 1x mes C. Número Total de los Miembros del Hogar (Niños y Adultos) Asistencia pública/ manutención de menores o pension matrimonial Los últimos cuatro números del Seguro Social (SSN) del asalariado(a) principal u otro adulto del hogar Con qué frecuencia? Pension/Jubilacion/ Con qué frecuencia? semana quincenal 2x mes 1x mes otros ingresos semana quincenal 2x mes 1x mes X X X X X Indique si no hay SSN PASO Información de contacto y firma de adulto Certifico (juro) que toda la información en esta solicitud es cierta y que todo ingreso se ha reportado. Entiendo que esta información se da con el propósito de recibir fondos federales y que los funcionarios de la escuela pueden verificar tal información. Soy consciente de que si falsifico información a propósito, mis hijos pueden perder los beneficios de comida y me pueden procesar de acuerdo con las leyes estatales y federales que aplican. Calle y número de casa (si está disponible) Apartamento # Ciudad Estado Código Postal Teléfono y correo electrónico (opcional) Nombre del adulto que completa el formulario (Favor escribir en letra de molde): Firma del adulto que llenó el formulario: Fecha de hoy:

13 OPCIONAL Identidades Raciales y Étnicas de los Niños Le pedimos información acerca de la raza e etnicidad de sus niños. Esta informacion es importante pues nos ayuda a asegurar un servicio pleno a la comunidad. Responder a esta sección es opcional y no afecta la elegibilidad de sus niños para comida gratuita o a precio reducio. Etnicidad (Marque uno): Hispano or Latino No Hispano or Latino Raza (Marque uno o más): Indio Americano o Nativo de Alaska Asiático Negro o Americano Africano Nativo de Hawái u Otro Isleño del Pacifico Sur Blanco La Ley Nacional de Comedores Escolares Richard B. Russell pide la información arriba en esta solicitud. No tiene que dar la información, pero si usted no la provee, no podemos aprobar comida gratuita o de precio reducido para sus niños. Usted debe incluir los últimos cuatro números del Seguro Social (SSN) del miembro adulto que firma la solicitud. Los últimos cuatro números del SSN no se requieren cuando usted solicita de parte de un niño adoptivo temporal o usted incluye un número de caso del Programa de Asistencia Nutricional Suplementaria (SNAP, por sus siglas en inglés), el Programa de Asistencia Temporal Para Familias Necesitadas (TANF, por sus siglas en inglés) o el Programa de Distribución de Comida en Reservaciones Indígenas (FDPIR, por sus siglas en inglés) u otra identificación FDPIR de su niño. Tampoco necesita indicar el número del SSN si el miembro adulto del hogar que firma la solicitud no lo tiene. Utilizamos su información para determinar si su niño es elegible para la comida gratuita o de precio reducido, y para administrar y hacer respetar los programas de almuerzo y desayuno. Podemos compartir la información sobre su elegibilidad con los programas de educación, salud, y nutrición para ayudarles a evaluar, financiar, o determinar los beneficios de sus programas, así como con los auditores de revisión de programas, y los oficiales encargados de investigar violaciones del reglamento programático. El Departamento de Agricultura de los Estados Unidos (USDA, por sus siglas en inglés) prohíbe la discriminación contra sus clientes, empleados y solicitantes de empleo basada en raza, color, origen nacional, edad, discapacidad, sexo, identidad de género, religión, o retaliación por haber iniciado una queja de derechos civiles. También se prohíbe la discriminación, cuando es pertinente, basada en creencia política, estado civil, estado familiar o paterno, orientación sexual, información genética, o cuando todo o parte del ingreso de una persona viene de cualquier programa pública asistencial, en el empleo, o en cualquier programa o actividad realizados o financiados por el Departamento. (No todas las bases prohibidas aplican en todos los programas y/o actividades de empleo.) Si usted desea poner una queja de derechos civiles de discriminación, complete el Formulario del USDA de Queja de Discriminación que se encuentra en el sitio web, El formulario también puede obtenerse en cualquier oficina del USDA, o llamando al (866) Envíe por correo el formulario o carta de queja completada a la siguiente dirección: Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C , o al fax (202) , o por correo electrónico a: programa.intake@usda.gov. Personas sordas, con discapacidad auditiva o de habla, pueden contactar al USDA por medio del Servicio Federal de Retransmisión al (800) ; o (800) (español). El USDA es un proveedor y empleador de igualdad de oportunidades. For School Use Only Do Not Write Below This Line Determining Officials (DO) for the Local Education Agency MUST complete this section. Annual Income Conversion: Weekly X 52 Every 2 weeks X 26 Twice a Month X 24 Monthly X 12 (Only convert to annual income if there are different frequencies of income listed in Step 3.) Date Certified on DC List: Directly Certified Based on the State Direct Certification List SNAP/TFA Household (Reminder: The DO must confirm a handwritten SNAP/TFA number) Foster Child Head Start Confirmed Homeless or Runaway Income Household: Total household income: per Household Size: Application approved for: Free Meals Reduced-Price Meals Application Denied Date Notice Sent: Signature of Determining Official: Date:

14 COMO SOLICITAR COMIDA ESCOLAR GRATUITA Y DE PRECIO REDUCIDO Favor utilice estas instrucciones para llenar la solicitud para recibir comida escolar gratuita o de precio reducido. Solamente necesita completar una solicitud por hogar, aún si sus hijos asisten a más de una escuela en [Distrito Escolar]. Debe llenar completamente la solicitud para solicitar comida gratuita o de precio reducido para sus hijos. Cada paso de las instrucciones corresponde a los pasos en la solicitud. Si en algún momento usted no está seguro cómo responder, favor de contactar [Escuela/distrito escolar a contactar teléfono y correo electrónico preferible]. Favor use una pluma (no lapiz) al llenar la solicitud y escriba en letra clara y de molde. PASO 1- LISTA DE TODOS LOS BEBÉS, NIÑOS Y ESTUDIATES HASTA EL GRADO 12 MIEMBROS DE SU HOGAR Diga cuántos bebés, niños y estudiantes viven en su hogar. Ellos no tienen que ser parientes para ser parte de su hogar. Llista los nombres de cada niño. Para cada niño, imprima su primer nombre, inicial de su segundo nombre, y apellido. Ponga sólo un nombre por línea. Al escribir los nombres, ponga una sola letra en cada casilla. No continúe si no hay más casillas. Si no le alcanzan las líneas del formulario, agregue una hoja con toda la información requerida para los niños adicionales. Marque la columna titulada Estudiante para indicar los niños que asisten a [nombre de la escuela/distrito escolar aquí]. Si algún niño(a) está con usted como adoptivo temporal, marque la casilla titulada Foster Child al lado del nombre del niño(a). Los niños adoptivos temporales que viven con usted se considerarán como miembros de su hogar y deben ser listados en su solicitud. Si usted cree que algún niño listado en esta sección puede caber en estas descripciones, favor marque la casilla al lado del nombre del niño(a) titulada Sin Hogar, migrante, Fugitivo y complete todos los pasos de la solicitud. PASO 2- PROGRAMAS DE ASISTENCIA: SNAP, TANF O FDPIR Paricipa algún miembro de su hogar, incluyéndose a usted, en uno o mas de los siguientes programas de asistencia: SNAP, TANF, O FDPIR? SÍ - Marque e indique un número de caso para el SNAP, TANF, o FDPIR. Usted necesita escribir sólo un número de caso. Si usted participa en uno de estos programas y desconoce su número de caso, contacte [información de contacto para el Estado /agencia local]. Usted debe proveer un número de caso en su solicitud si usted marcó the box. No- Si nadie en su hogar participa en alguno de los programas mencionados arriba, deje en blanco PASO 2. PASO 3- DECLARE EL INGRESO DE TODOS LOS MIEMBROS DEL HOGAR A. Reporte todos los ingresos de los niños. Vea tabla titulada Fuentes de Ingreso Para Niños en estas instrucciones y reporte el ingreso total bruto para TODOS los niños listados en Paso 1 en la casilla señalada Ingreso Total del Niño. Solamente incluya el ingreso de los niños adoptivos temporales si usted está solicitando para ellos junto con el resto de los miembros de su hogar. Es opcional incluir en la lista los niños adoptivos temporales que viven en el hogar. a. Ingreso del niño se refiere al dinero recibido de una fuente fuera del hogar y pagado directamente a sus niños. Muchos hogares no reciben ingreso para sus niños. Use la tabla abajo para determinar si su hogar tiene ingreso del niño para reportar. FUENTES DE INGRESOS PARA NIÑOS Fuentes de Ingreso del Niño Ejemplos Ganancia del trabajo Un niño tiene un trabajo que le paga un salario. Seguro Social Un niño es ciego o con incapacidad que recibe beneficios de Pagos por Incapacidad seguro social. Beneficios Para Sobrevivientes Ingresos de otras personas que no pertenecen al hogar Uno de los padres tiene una incapacidad, es pensionado o difunto, y su hijo recibe beneficios de seguro social. Amigos o familiares que generalmente mandan dinero al niño. Ingreso de cualquier otra fuente Un niño recibe un ingreso de fondos de jubilación privados, anualidades o fideicomiso.

15 B. Reporte todos los ingresos de los adultos miembros del hogar. Escriba en letra de molde el nombre de cada miembro del hogar en las casillas marcadas Nombres de Miembros Adultos del Hogar (Primer Nombre y Apellido). No incluya a los miembros del hogar usted puso en el PASO 1. Si un(a) niño(a) listado(a) en PASO 1 tiene ingreso, siga las instrucciones en PASO 3, Parte A. Reporte SOLAMENTE el ingreso bruto total. Reporte todo ingreso en dólares redondeados sin incluir centavos. El ingreso bruto es el ingreso total recibido antes de restar impuestos o deducciones. Mucha gente considera ingreso como la cantidad que le queda y no el total que le pagan. Asegúrese que el ingreso reportado en esta solicitud es la cantidad antes de pagar impuestos, prima de seguro, o cualquier otra cantidad sacada de su sueldo. Marque la frecuencia con que recibe ingresos usando las casillas al derecho de cada línea. Escriba 0 (cero) en las casillas donde no hay ingresos que reportar. Si deja una casilla para ingreso en blanco o vacía, se va a considerar como cero y usted está certificando que no hay ingreso para reportar. Si los oficiales locales tienen disponible información de que el ingreso de su hogar fue reportado incorrectamente, su solicitud será verificada. Fuentes de Ingresos para Adultos Ingresos del Trabajo Asistencia Pensión/Jubilación/Otros Ingresos Pública/Manutención de Menores/Pensión Sueldo, pagos, bonos en efectivo Ingreso neto de trabajo independiente (finca o negocio propio) Pagos por huelgas Si está en las Fuerzas Armadas de los EE.UU: Sueldo básico y bonos en efectivo (No incluya pago de combate, FSSA o ayudas privadas de vivienda) Ayudas para vivienda fuera de la base militar, comida y ropa Matrimonial Beneficios de Desempleo Compensación laboral Ingreso Complementario del Seguro Social (SSI) Asistencia en efectivo del gobierno estatal o local Pensión matrimonial Manutención de menores Beneficios para los veteranos de las Fuerzas Armadas de los EE.UU. Seguro Social (incluyendo jubilación de ferrocarriles y enfermedad del pulmón de minero) Pensiones privadas o por discapacidad Ingresos de herencia o fideicomisos Anualidades Ingreso de inversiones Intereses Ingresos de alquiler Pagos regulares en efectivo de fuentes afuera del hogar C. Reporte el Número Total de Personas en el Hogar y escriba los últimos cuatro números del Seguro Social. Ponga el número total de los miembros del hogar en el espacio Número Total de los Miembros del Hogar (Niños y Adultos). Este número DEBE ser igual a la suma de los miembros del hogar listados en el PASO 1 y el PASO 3. El/la asalariado/(a) principal u otro miembro adulto del hogar debe escribir los últimos cuatro números del Seguro Social en el espacio indicado. Usted es elegible para solicitar beneficios aun si no tiene un número del Seguro Social. Si ningún miembro adulto del hogar tiene número del Seguro Social, deje en blanco este espacio y ponga una X en la casilla a la derecha titulada Marque si no hay SS#. PASO 4: INFORMACIÓN DE CONTACTO Y FIRMA DE ADULTO Toda solicitud debe ser firmada por un miembro adulto del hogar. Al firmar la solicitud, ese miembro del hogar certifica que toda la información ha sido reportada de una manera completa y verdadera. Antes de completar esta sección, asegúrese también de leer las declaraciones de derechos civiles y de privacidad al reverso de la solicitud.

16 Provea su información de contacto. Si tiene dirección permanente, escriba su dirección actual en los espacios correspondientes. Si no tiene una dirección permanente, esto no quiere decir que sus hijos no son elegibles para recibir comida escolar gratuita o de precio reducido. Poner un número de teléfono, correo electrónico es opcional, pero nos ayuda a contactarle rápidamente si necesitamos hacerlo. Firme y escriba su nombre en letra de molde. Escriba la Fecha de Hoy. INFORMACION OPCIONAL Al reverso de la solicitud, pedimos que usted dé información sobre la raza y etnicidad de sus niños. Esta información es opcional y no afecta la elegibilidad de sus hijos para recibir comida gratuita escolar o de precio reducido. La parte posterior también proporciona un lugar para que usted pueda dar o negar permiso a la escuela para compartir su información con otros programas que también pueden ser capaces de proporcionar recursos para sus hijos. Lea esta información y marque la casilla junto a Sí para indicar a cuales programas usted le da permiso a la escuela compartir su información de contacto. Marque la casilla junto a NO si usted no quiere que la escuela comparta su información de contacto con estos otros programas. Incluya una firma del padre o tutor y la fecha en la parte al fondo de la página. Esta sección también incluye información importante acerca de la privacidad y los derechos civiles. Por favor, lea estas declaraciones antes de presentar la solicitud

17 Greenwich High School Application for Free and Reduced-price School Meals Complete this application if you have NO SIBLINGS IN LOWER SCHOOLS Application No: STEP 1 List ALL Household Members who are infants, children, and students up to and including grade 12 (if more spaces are required for additional names, attach another sheet of paper) Definition of Household Member: Anyone who is living with you and shares income and expenses, even if not related. Children in Foster care and children who meet the definition of Homeless, Migrant or Runaway are eligible for free meals. Read How to Apply for Free and Reduced Price School Meals for more information. Student? Child s First Name MI Child s Last Name Foster Head Even Homeless or School Grade Yes No Check all that apply Start Start Runaway STEP 2 Do any Household Members (including you) currently participate in one or more of the following Assistance Programs - SNAP OR TFA: Check one: YES or NO (This does NOT include medical (HUSKY) benefits.) To quicken the approval process, it is strongly recommended that you submit proof of SNAP or TFA eligibility with this application. See instructions. If NO household member participates in SNAP or TFA, skip Step 2 and complete STEP 3. If a household member does participate in SNAP or TFA, write a SNAP OR TFA case number here and then go to STEP 4 (Do not complete STEP 3) STEP 3 Report Income for ALL Household Members (Skip this step if you wrote a SNAP or TFA Number in STEP 2) Case Number: Write only one case number in this space. Please read How to Apply for Free and Reduced Price School Meals for more information. The Sources of Income for Children section will help you with the Child Income question. The Sources of Income for Adults section will help you with the All Adult Household Members section. A. Child Income Sometimes children in the household earn income. Please include the TOTAL income earned by all Child Household Members listed in STEP 1 here. $ Child income Weekly Bi-Weekly 2x Month Monthly How often? Weekly Bi-Weekly 2x Month Monthly B. All Adult Household Members (including yourself) List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total income for each source in whole dollars only. If they do not receive income from any source, write 0. If you enter 0 or leave any fields blank, you are certifying (promising) that there is no income to report. Name of Adult Household Members (First and Last) How often? Earnings from Work Weekly Bi-Weekly 2x Month Monthly Public Assistance/ Child Support/Alimony How often? Pensions/Retirement/ All Other Income How often? Weekly Bi-Weekly 2x Month Monthly Total Household Members (Children and Adults Step 1 & Step 3) Last Four Digits of Social Security Number (SSN) of Primary Wage Earner or Other Adult Household Member X X X X X Check if no SSN STEP 4 Contact Information information and Adult adult Signature signature I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws. Street Address (if available) Apt # City State Zip Daytime Phone and (optional) Printed name of adult completing the form Signature of adult completing the form Today s date

18 OPTIONAL Children's Racial and Ethnic Identities We are required to ask for information about your children s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children s eligibility for free or reduced price meals. Ethnicity (check one): Race (check one or more): Hispanic or Latino Not Hispanic or Latino American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White For School Use Only Do Not Write Below This Line Determining Officials (DO) for the Local Education Agency MUST complete this section. Annual Income Conversion: Weekly X 52 Every 2 weeks X 26 Twice a Month X 24 Monthly X 12 (Only convert to annual income if there are different frequencies of income listed in Step 3.) Date Certified on DC List: Directly Certified Based on the State Direct Certification List SNAP/TFA Household (Reminder: The DO must confirm a handwritten SNAP/TFA number) Foster Child Head Start Confirmed Homeless or Runaway Income Household: Total household income: per Household Size: Application approved for: Free Meals Reduced-Price Meals Application Denied Date Notice Sent: Signature of Determining Official: Date:

19 Rev. 5/19/2015 Application Instructions Page 1 of 4 HOW TO APPLY FOR FREE AND REDUCED-PRICE SCHOOL MEALS Please use these instructions to help you fill out the application for free or reduced-price school meals. You only need to submit one application per household, even if your children attend more than one school in [School District]. The application must be filled out completely to certify your children for free or reduced-price school meals [or free milk if the school participates in the Special Milk Program.] Please follow these instructions in order! Each step of the instructions is the same as the steps on your application. If at any time you are not sure what to do next, please contact [school/school district contact here---phone and preferred]. PLEASE USE A PEN (NOT A PENCIL) WHEN FILLING OUT THE APPLICATION AND DO YOUR BEST TO PRINT CLEARLY. STEP 1: LIST ALL HOUSEHOLD MEMBERS WHO ARE INFANTS, CHILDREN, AND STUDENTS UP TO AND INCLUDING GRADE 12 Tell us how many infants, children, and school students live in your household. They do NOT have to be related to you to be a part of your household. Who should I list here? When filling out this section, please include all members in your household who are: Children age 18 or under and are supported with the household s income; In your care under a foster arrangement, or qualify as homeless or runaway youth; Students attending [school/school system here], regardless of age. A. List each child s name. For each child, print their first name, middle initial and last name. Use one line of the application for each child. Please print clearly. If there are more children present than lines on the application, attach a second piece of paper with all required information for the additional children. B. List the name of the school and grade (if applicable) that each child attends and check the box to confirm if the child is a student at the school. C. Do you have any foster children? If any children listed are foster children, mark the Foster Child box next to the child s name. Foster children who live with you may count as members of your household and should be listed on your application. If you are only applying for foster children, after completing STEP 1, skip to STEP 4 of the application and these instructions. D. Are any children enrolled in a federal Head Start or Even Start Program in the school system? If you believe any child listed in this section may meet this description, please mark the Head Start or Even Start box next to the child s name and complete all steps of the application. E. Are any children homeless or runaway? If you believe any child listed in this section may meet this description, please mark the Homeless or Runaway box next to the child s name and complete all steps of the application.

20 Rev. 6/5/2015 Application Instructions Page 2 of 4 STEP 2: HOUSEHOLD MEMBER PARTICIPATION IN ONE OR MORE ASSISTANCE PROGRAMS SNAP OR TFA (THIS DOES NOT INCLUDE MEDICAL OR HUSKY BENEFITS) If anyone in your household participates in the assistance programs listed below, your children are eligible for free school meals: The Supplemental Nutrition Assistance Program (SNAP) or Temporary Family Assistance (TFA) A. IF NO ONE IN YOUR HOUSEHOLD PARTICIPATES IN ANY OF THE ABOVE LISTED PROGRAMS: Skip to STEP 3 on these instructions and STEP 3 on your application. Leave STEP 2 blank. B. IF ANYONE IN YOUR HOUSEHOLD PARTICIPATES IN ANY OF THE ABOVE LISTED PROGRAMS: Check off Yes and provide a case number for SNAP or TFA. You only need to write one case number. If you participate in one of these programs and do not know your case number, contact your DSS Social Worker. Note: Do not use a HUSKY Medical Benefits Number since this number is not a SNAP or TFA case number. It is also recommended (but not required) that you submit proof of this SNAP or TFA case number when you submit the application for processing. Proof does NOT include a copy of the CONNECT card. Skip to STEP 4. STEP 3: REPORT INCOME FOR ALL HOUSEHOLD MEMBERS A. Report all income earned by children. Refer to the chart titled Sources of Income for Children in these instructions and report the combined gross income for ALL children listed in Step 1 in your household in the box marked Total Child Income. Only count foster children s income if you are applying for them together with the rest of your household. It is optional for the household to list foster children living with them as part of the household. What is Child Income? Child income is money received from outside your household that is paid directly to your children. Many households do not have any child income. Use the chart below to determine if your household has child income to report. Sources of Child Income Sources of Income for Children Examples Earnings from work A child has a job where they earn a salary or wages. Social Security o Disability Payments o 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 persons outside the household A friend or extended family member regularly gives a child spending money. Income from any other source A child receives income from a private pension fund, annuity, or trust.