Instructions for Applying

Household member is any child or adult living with you.

IF YOUR HOUSEHOLD RECEIVES BENEFITS FROM SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP), TEMPORARY AsSISTANCE FOR NEEDY FAMILIES OR THE FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS (FDPIR), FOLLOW THESE INSTRUCTIONS:

• Part 1: List all household members and the name of school for each child.
• Part 2: List the case number for any household member (including adults) receiving SNAP, TANF or FDPIR benefits.
• Part 3: Skip this part.
• Part 4: Skip this part.
• Part 5: Sign the form. The last four digits of a Social Security Number are not necessary.
• Part 6: Answer this question if you choose to.

IF NO ONE IN YOUR HOUSEHOLD GETS STATE SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP), OR TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) BENEFITS AND IF ANY CHILD IN YOUR HOUSEHOLD IS HOMELESS, A MIGRANT OR RUNAWAY, FOLLOW THESE INSTRUCTIONS:

• Part 1: List all household members and the name of school for each child.
• Part 2: Skip this part.
• Part 3: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your child’s school.
• Part 4: Complete only if a child in your household isn’t eligible under Part 3. See instructions for All Other Households.
• Part 5: Sign the form. The last four digits of a Social Security Number are not necessary if you didn’t need to fill in Part 4.
• Part 6: Answer this question if you choose to.

IF YOU ARE APPLYING FOR A FOSTER CHILD, FOLLOW THESE INSTRUCTIONS:

If all children in the household are foster children:

• Part 1: List all foster children and the school name for each child. Check the box indicating the child is a foster child.
• Part 2: Skip this part.
• Part 3: Skip this part.
• Part 4: Skip this part.
• Part 5: Sign the form. The last four digits of a Social Security Number are not necessary.
• Part 6: Answer this question if you choose to.

If some of the children in the household are foster children:

• Part 1: List all household members and the name of school for each child. For any person, including children, with no income, you must check the “No Income” box. Check the box if the child is a foster child.
• Part 2: If the household does not have a case number, skip this part.
• Part 3: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your child’s school. If not, skip this part.
• Part 4: Follow these instructions to report total household income from this month or last month.
• Box 1–Name: List all household members with income.
• Box 2 –Gross Income and How Often It Was Received: For each household member, list each type of income received for the month. You must tell us how often the money is received—weekly, every other week, twice a month or monthly. For earnings, be sure to list the gross income, not the take‐home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you.
  • For other income, list the amount each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), and disability benefits.
  • Under All Other Income, list Worker’s Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income. Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster payments received by the family from the placing agency. For ONLY the self-employed, under Earnings from Work, report income after expenses. This is for your business, farm, or rental property. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income.
• Part 5: Adult household member must sign the form and list the last four digits of their Social Security Number (or mark the box if s/he doesn’t have one).
• Part 6: Answer this question, if you choose.

ALL OTHER HOUSEHOLDS, INCLUDING WIC HOUSEHOLDS, FOLLOW THESE INSTRUCTIONS:

• Part 1: List all household members and the name of school for each child. For any person, including children, with no income, you must check the “No Income” box.
• Part 2: If the household does not have a case number, skip this part.
• Part 3: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your child’s school. If not, skip this part.
• Part 4: Follow these instructions to report total household income from this month or last month.
  • Box 1–Name: List all household members with income.
  • Box 2 –Gross Income and How Often It Was Received: For each household member, list each type of income received for the month. You must tell us how often the money is received—weekly, every other week, twice a month or monthly. For earnings, be sure to list the gross income, not the take‐home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you.
  • For other income, list the amount each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), and disability benefits. Under All Other Income, list Worker’s Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income. Do not include income from
  • SNAP, FDPIR, WIC, Federal education benefits and foster payments received by the family from the placing agency. For ONLY the self‐employed, under Earnings from Work, report income after expenses. This is for your business, farm, or rental property. Do not include income from SNAP, FDPIR, WIC or Federal education benefits. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income.
• Part 5: Adult household member must sign the form and list the last four digits of their Social Security Number (or mark the box if s/he doesn’t have one).
• Part 6: Answer, this question if you choose.

Your children may qualify for free or reduced price meals if your household income falls at or below the limits found at this website: http://www.fns.usda.gov/cnd/governance/notices/iegs/RPieg.pdf

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.

Non‐discrimination Statement: This explains what to do if you believe you have been treated unfairly. “In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250‐9410 or call toll free (866) 632‐9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877‐8339; or (800) 845‐6136 (Spanish). USDA is an equal opportunity provider and employer.”