Household Application Free and Reduced-Price School Meals

STEP 1: List ALL Household Members who are infants, children, and students up to and including 12 (if more spaces are required for additional names, contact Kelly Aimery at aimeryk@masonk12.net). 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 definition of Homeless, Migrant or Runaway are eligible for free meals.

Child 1: First Name

Child 1: Middle Initial

Child 1: Last Name

Is child 1 a student? Yes No

Child 1: School

Child 1: Grade Level

Child 1: Foster Child Yes No

Child 1: Homeless, Migrant, Runaway Yes No

Child 2: First Name

Child 2: Middle Initial

Child 2: Last Name

Child 2: Student Yes No

Child 2: School

Child 2: Grade

Child 2: Foster Child Yes No

Child 2: Homeless, Migrant, Runaway Yes No

Child 3: First Name

Child 3: Middle Initial

Child 3: Last Name

Child 3: Student Yes No

Child 3: School

Child 3: Grade

Child 3: Foster Child Yes No

Child 3: Homeless, Migrant, Runaway Yes No

Child 4: First Name

Child 4: Middle Initial

Child 4: Last Name

Child 4: Student Yes No

Child 4: School

Child 4: Grade Level

Child 4: Foster Child Yes No

Child 4: Homeless, Migrant, Runaway Yes No

Child 5: First Name

Child 5: Middle Initial

Child 5: Last Name

Child 5: Student Yes No

Child 5: School

Child 5: Grade Level

Child 5: Foster Child Yes No

Child 5: Homeless, Migrant, Runaway Yes No

STEP 2: Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR? No Yes

If no, go to STEP 3. If yes, write one case number here, then go to STEP 4 (do not complete STEP 3).

STEP 3: Report income for ALL Household Members (Skip this step if you answered “YES” to STEP 2) . Unsure what income to include here? Review the charts titled, “Sources of Income” below for more information. The “Sources of Income for Children” chart will help you with the Child Income section. The “Sources of Income for Adults” chart will help you with the All Adult Household Members Section.

A. Child Income: Sometimes children in the household earn or receive income. Please include the TOTAL income received by All Household Members listed in STEP 1 here.

How Often? Weekly Bi-Weekly 2x Monthly Monthly Annually

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 gross income (before taxes) for each source in whole dollars (no cents) 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.

Household Member 1: First and last Name

Household Member 1: Earnings from Work

Household Member 1: How often? Weekly Bi-Weekly 2x Month Monthly Annually

Household Member 1: Public Assistance/ Alimony/Child Support

Household Member 1: How Often? Weekly Bi-Weekly 2x Month Monthly Annually

Household Member 1: Pensions/Retirement/All other income

Household Member 1: How often? Weekly Bi-weekly 2x Monthly Monthly Annually

Household Member 2: First and last Name

Household Member 2: Earnings from Work

Household Member 2: How often? Weekly Bi-Weekly 2x Month Monthly Annually

Household Member 2: Public Assistance/ Alimony/Child Support

Household Member 2: How Often? Weekly Bit-Weekly 2x Monthly Monthly Annually

Household Member 2: Pensions/Retirement/All other income

Household Member 2: How Often? Weekly Bi-Weekly 2x Monthly Monthly Annually

Household Member 3: First and last Name

Household Member 3: Earnings from Work

Household Member 3: How often? Weekly Bi-Weekly 2x Month Monthly Annually

Household Member 3: Public Assistance/ Alimony/Child Support

Household Member 3: How Often? Weekly Bi-Weekly 2x Monthly Monthly Annuallt

Household Member 3: Pensions/Retirement/All other income

Household Member 3: How Often? Weekly Bi-Weekly 2x Monthly Monthly Annually

Household Member 4: First and last Name

Household Member 4: Earnings from Work

Household Member 4: How often? Weekly Bi-Weekly 2x Month Monthly Annually

Household Member 4: Public Assistance/ Alimony/Child Support

Household Member 4: How Often? Weekly Bi-Weekly 2x Month Monthly Annually

Household Member 4: Pensions/Retirement/All other income

Household Member 4: How Often? Weekly Bi-Weekly 2x Monthly Monthly Annually

Household Member 5: First and last Name

Household Member 5: Earnings from Work

Household Member 5: How often? Weekly Bi-Weekly 2x Month Monthly Annually

Household Member 5: Public Assistance/ Alimony/Child Support

Household Member 5: How Often? Weekly Bi-Weekly 2x Monthly Monthly Annually

Household Member 5: Pensions/Retirement/All other income

Household Member 5: How Often? Weekly Bi-Weekly 2x Monthly Monthly Annually

Total Household Members (Children and Adults)

Last four digits of Social Security Number (SSN) of Primary Wage Earner or Other Adult Household Member

Check if no SSN

STEP 4: Contact information and adult 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)

City

State

Zip Code

Daytime Phone

Email

Printed Name of Adult Signing Form

Today's Date MM/DD/YYYY

OPTIONAL: Children's Racial and Ethical 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 child(s) eligibility for free or reduced-price meals.

Ethnicity (check one) Hispanic or Latino Not Hispanic or Latino

Race (check one or more) 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 investigate 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 (https://www.ocio.usda.gov/sites/default/files/docs/2012/Complain_combined_6_8_12.pdf), (AD-3027) found online at: How to File a Complaint (https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complaint), 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:

1. US Mail: U.S. Department of the Assistant Secretary for Civil Rights, 1400 Independence Avenue SW, Washington, D.C. 20250-9410

2. Fax: (202) 690-7442 OR

3. Email: program.intake@usda.gov

This institution is an equal opportunity provider.