MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01CC5F86.989E7680" This document is a Single File Web Page, also known as a Web Archive file. If you are seeing this message, your browser or editor doesn't support Web Archive files. Please download a browser that supports Web Archive, such as Windows® Internet Explorer®. ------=_NextPart_01CC5F86.989E7680 Content-Location: file:///C:/E3293A52/KYFRApplication-2011-12.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Application & Instructions

Free and Reduced Price School Meals Application = and Verification Forms

  School Year 2011-2012____
        =          Instructions For School Districts

This packet contains prototype for= ms:        &= nbsp;

 

Required information that must be provided to households:

 

Required information for households selected for verificatio= n of eligibility information materials:

 

Optional application-related materials that may be provided to households:

 

The pages are designed to be pr= inted on 8½” by 11” paper. Some pages may be printed front and back. You will need to identify the benefits that are offered in your schoo= l, such as afterschool snacks.   The [bold, bracketed fields] indicate where you need to insert school district specific information. For example, you must include = your district’s no-charge telephone number for verification assistance on = the verification materials. If these materials have not been modified to include your State’s name for the Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp Program, Temporary Assistance to Needy Families (KT= AP), State Children’s Health Insurance Program (KCHIP), or, if applicable,= to add Food Distribution Program on Indian Reservations (FDPIR), you should in= sert this information as appropriate. This prototype application package includes information regarding the exclusion of housing allowance for those in the Military Housing Privatization Initiative.  If this is not pertinent to your sc= hool district, please modify as appropriate.

 

Your= State agency may require you to submit your application package for approval.  If you have questions, contact:

 School and Community Nutrition=

500 = Mero Street

Fran= kfort, KY 40601

 

LAWRENCE COUNTY SCHOOLS

Dear Parent/Guardian:

Chil= dren need healthy meals to learn. La= wrence County Schools offers healthy meals every school day. Breakfast costs $1.00 at all sc= hools; lunch costs $1.50 ($1.75 at LCH= S). Your children may qualify for free meals or for reduced price meals. Reduce= d price is $0.30 for breakfast and $0.40<= /u> for lunch.

 

  1. Do I need to fill out an application for each child?  No. Complete the applicati= on to apply for free or reduced price meals. 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: = Karen Ferrell, Lawrence County Board of Education, 50 Bulldog Lane,     Louisa, KY 4= 1230 or call 606-638-9671 ext 26 if= you need assistance.
  2. Who can get free meals? All children in households= receiving benefits from SNAP or KTAP<= /u>, can get free meals regardless of your income. Also, your children can = get free meals if your household’s gross income is within the free limits on the Federal Income Eligibility Guidelines.=
  3. CAN FOSTER CHILDREN GET FREE MEALS?  Yes, foster children that are under the legal responsibility of= a foster care agency or court, are eligible for free meals.  Any foster child in the house= hold is eligible for free meals regardless of income.

 <= /span>

  1. Can homeless, runaway, and migrant children get free meals? Yes, children who meet the definition of homeless, runaway, or migrant qualify for free meals.  If you haven’t been tol= d your children will get free meals, please call or e-mail Thomas Gibson, Lawrence County Board of Education, at 606-638-9671 ext 17 or Thomas.gibson@lawrence.kyschools.= us to see if they qualify.  =
  2. WHO CAN GET REDUCED PRICE MEALS?  Your children can get low cost meals if your household income is within the reduced price limits on t= he Federal Eligibility Income Chart, shown on this application.  
  3. SHOULD I FILL OUT AN APPLICATION IF I RECEIVE= D A LETTER THIS SCHOOL YEAR SAYING MY CHILDREN ARE APPROVED FOR FREE MEALS?  Please read the l= etter you got carefully and follow the instructions.  Call the LCBOE at 606-638-9671 ext 26 if you have questions.  
  4. MY CHILD’S APPLICATION WAS APPROVED LAST YEAR.  DO I NEED TO FILL = OUT ANOTHER ONE?  Yes.  Your child’s applicatio= n is only good for that school year and for the first few days of this scho= ol year.  You must send in a= new application unless the school told you that your child is eligible for the new sch= ool year.  =
  5. I GET WIC.&n= bsp; CAN MY CHILD(REN) GET FREE MEALS?  Children in households participating in WIC may be eligible for free or reduced price meals.  Please fill out a= n application.
  6. Will the information I giv= e be checked? Yes and we may also ask you to send written proof.
  7. If I don’t qualify n= ow, may I apply later? Ye= s, 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 lim= it.
  8. 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:
    Mike Armstro= ng, Superintendent         = Phone: 606-638-9671        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;      Address: Lawrence County Board of Education, 50 Bulldog Lane, Louisa, KY 41230<= /span>=
  9. May I apply if someone in = my household is not a U.S. citizen? Yes. You or your child(re= n) do not have to be U.S. citizens to qualify for free or reduced price meal= s. 
  10. Who should I include as me= mbers of my household? You must include all people living in your household, related or= not (such as grandparents, other relatives, or friends) who share income a= nd expenses. You must include yourself and all children living with you.<= span style=3D'mso-spacerun:yes'>  If you live with other people= who are economically independent (for example, people who you do not suppo= rt, who do not share income with you or your children, and who pay a pro-r= ated share of expenses), do not include them.
  11. What if my income is not a= lways the same? = List the amount that you normally receive. For example, if you normally mak= e $1000 each month, but you missed some work last month and only made $900, put down that you made $1000 per month.&n= bsp; If you normally get overtime, include it, but do not include it= if you only work overtime sometimes.&nbs= p; If you have lost a job or had your hours or wages reduced, use = your current income.=
  12. We are in the military. do= we include our housing allowance as income? = If you get an off-base housing allowance, it must be included as income. Howe= ver, if your housing is part of the Military Housing Privatization Initiati= ve, do not include your housing allowance as income.
  13. My spouse is deployed to a combat zone. is her combat pay counted as income? <= span style=3D'mso-spacerun:yes'> No, if the combat pay is recei= ved in addition to her basic pay because of her deployment and it wasn’t received before she was deployed, combat pay is not co= unted as income.  Contact your = school for more information.
  14. My family needs more help.= Are there other programs we might apply for? To find out how to apply = for SNAP, KTAP or other a= ssistance benefits, contact your local assistance office.

 

If y= ou have other questions or need help, call 606-638-9671

Si necesita ayuda, por favor llame al teléfono: = 606-638-9671        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;   

Si vous vo= udriez d’aide, contactez nous au numero <= /i>606-638-9671=

 

Sinc= erely,

Lawrence County Schools Food Service

INSTRUCTIONS FOR APPLYING

A household member is any child or adult living wi= th you.

If your househo= ld receives benefits from SNAP OR = KTAP, 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 (includi= ng adults) receiving   SNAP= or KTAP= benefits.

Part 3: Skip this part.

Part 4: Skip this part.

Part 5: Sign the form. The last four digits of a Social Securi= ty Number are not necessary.=

Part 6: Answer this question if you choose to.

 

if no one in your household gets= SNAP= or KTAP= benefits and if any child in your household is homeless, a migrant or runaway, follow these instructions:

&n= bsp;            = ;             <= /span>

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 LCBOE, Thomas Gibson @606-638-9671  

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 Securi= ty Number are not necessary if you didn’t need to fill in Part 4. <= /o:p>

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:  <= /span>

Part 1: List all foster children and the school name for each child.  Check the box indicati= ng 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 Securi= ty Number are not necessary.

Part 6: Answer this question if you choose to.

 

If some of the children= in the household are foster children:  <= /span>

Part 1: List all household members and the name of school for e= ach child. For any person, including children, with no income, you must check t= he “No Income” box.  = Check the box if the child is a foster child.&nb= sp;

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 LCBOE, Thomas Gibson @606-638-9671  .  If not, skip this part.

Part 4: Follow these instructions to report total household in= come from this month or last month.

·      =    Box 1–Name: List all household members with income.

·      =    Box 2 –Gross Income and How Often It Was Rec= eived: 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 o= ther income, list the amount each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Secur= ity Income (SSI), Veteran’s benefits (VA benefits), and disability benefi= ts. Under All Other Income, list Worker&#= 8217;s Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income. Do not incl= ude 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.=

 <= /p>

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 t= he “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 LCBOE, Thomas Gibson @606-638-9671  .  If not, skip this part.

Part 4: Follow these instructions to report total household in= come from this month or last month.

·         Box 1&#= 8211;Name: List all household members with income. <= /o:p>

·         Box 2 –Gross Income and How Often It Was Rec= eived: 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 o= ther income, list the amount each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Secur= ity Income (SSI), Veteran’s benefits (VA benefits), and disability benefi= ts. Under All Other Income, list Worker&#= 8217;s Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income. Do not incl= ude 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 inclu= de 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 d= oesn’t have one).

Part 6: Answer, this question if you choose.=


FREE AND REDUCED PRICE SCHOOL MEALS FAMI= LY APPLICATION

Part 1. all household members

 

Names of all ho= usehold members
(First, Middle Initial, Last)

Name of school for each child/or indicate  “NA” if child is not= in school

Check if a foster child (legal responsibility= of welfare agency or court) 

* If all children listed below are foster children, skip to Part 5 to sign this form. 

Check if NO income

 

 

 

q   

q&= nbsp;   

 

 

 

q   

q&= nbsp;   

 

 

 

q   

q&= nbsp;   

 

 

 

q   

q&= nbsp;   

 

 

 

q   

q&= nbsp;   

 

 

 

q   

q&= nbsp;   

 

Part 2.  BENEFITS

If any member of your household receives SNAP,<= strong> or KTAP ,<= /span> provide the name and case num= ber for the person who receives benefits and skip to part 5.  if no one receives these benefits, = skip to part 3.  <= /span>

name:____________________________________________________________________<= span style=3D'mso-spacerun:yes'>  Case number: __________________________________________________________

 

Part 3. If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call LCBOE,= Thomas Gibson @606-638-9671  Homeless  q  Migrant q  Runaway  q

 

  Part
4. Total Household Gross Income. You must tell us how much and how often.

 

1. Name=
(List only household members with income) =

2. Gross income and how often it was received

  fOR EXAMPLE:  WEEKLY, EVERY OTHER WEEK, TWICE MONTHLY, MONTHLY

 

Earnings From Work bef= ore deductions

Welfare, child support, alimony

Pensions, retirement, Social Security, SSI, VA benefits

All Other Income<= /o:p>

(Example)  Jane Smith=

 

 

 

 

 

$______/________<= /span>

$______/________<= /span>

$______/________<= /span>

$______/_______

 

$______/________<= /span>

$______/________<= /span>

$______/________<= /span>

$______/_______

 

$______/________<= /span>

$______/________<= /span>

$______/________<= /span>

$______/_______

 

$______/________<= /span>

$______/________<= /span>

$______/________<= /span>

$______/_______

 

$______/________<= /span>

$______/________<= /span>

$______/________<= /span>

$______/_______

 

$______/________<= /span>

$______/________<= /span>

$______/________<= /span>

$______/_______

 

Part 5. Signature and last four digits of Social Security Number (Adult must sign= )

An adult household member must sign the application. If Part 4 is completed, the adult s= igning the form also must list the last four digits of his or her Social Security Number or mark the “I do not have a Social Security Number” b= ox. (See Privacy Act Statement on the back of this page.)

 

I certify (promise) th= at all information on this application is true and that all income is report= ed. I understand that the school will get Federal funds based on the informat= ion I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted.    

Sign here: _______________________________________________________= _______________Print name:_____________________________

Date: ____________________________ 

Address:__________________________________________________________= ___________________________Phone Number:______________

City:_____________________________________________________________= ______________State:__________________Zip Code:___________

Last four digits of Social Security Number:  * * * - *<= span style=3D'mso-spacerun:yes'>  * - __ __ __ __    q I do not have a Social Secu= rity Number

Part 6. Children’s ethnic and racial identities (optional)

Choose one ethnicity:

Choose one or more (regardless= of ethnicity):       &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;     

q<= /span> Hispanic/Latino

q<= /span> Not Hispanic/Latino

q Asian       &nbs= p;        q<= /span> Am= erican Indian or Alaska Native         &nbs= p;         q Black or African American       &nbs= p;            &= nbsp;           &nbs= p;    

q White       &nbs= p;       q<= /span> Na= tive Hawaiian or other Pacific Islander       &nbs= p;  

Do NOt fill out this part. This is for school use only.<= /span>

Ann= ual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24 Monthly x 12

Total Income: ____________ Per: q Week, q Every 2 Weeks, q Twice A Month, q Month, q Year       Household size: ________

Categorical Eligibility: ___  Date Withdrawn: ________Eligibility: Free___  Reduced___  Denied___

 Reason: ____________= ____________________________________________________________________

Temporary: Free_____  Reduced_____  Time Pe= riod: ___________ (expires after _____ days)

Determining Official’s Signature: __________________________= ______________________ Date: ______________

Confirming Official’s Signature: ___________________________= __ Date: ___________

Verifying Official’s Signature: ____________________________= ___Date: ________

 

 

FEDERAL ELIGIBILITY INCOME CHA= RT For School Year  2011-12________

Household size

Yearly

Monthly

Weekly

1

20,147

1,679

388

2

27,214

2,268

524

3

34,281

2,857

660

4

41,348

3,446

796

5

48,415

4,035

932

6

55,482

4,624

1,067

7

62,549

5,213

1,203

8

69,616

5,802

1,339

Each additional person:

7,067

589

136

 

Your children may qualify for free or reduced price meals if your household inco= me falls at or below the limits on this chart.

 

 

 

 

 

 


Privacy Act Statement: This explains how we will use the information = you give us.

The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, b= ut if you do not, we cannot approve your child for free or reduced price meals.  You must include the l= ast four digits of the social security number of the adult household member who signs the application.  The la= st 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 F= ood Distribution Program on Indian Reservations (FDPIR) case number or other FD= PIR identifier for your child or when you indicate that the adult household mem= ber 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 progr= ams, auditors for program reviews, and law enforcement officials to help them lo= ok 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.&= nbsp; 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.&= #8221;

SHARING INFORMATION WITH MEDICAID/KCHIP<= /h1>

 

Dear Parent/Guardian:

If your children get free or reduced price school meals, = they may also be able to get free or low-cost health insurance through Medicaid or the State Children's Health Insurance Program (KCHIP). Children with health insurance are more likely to get regular health care and are le= ss likely to miss school because of sickness.

Because health insurance is so important to children̵= 7;s well-being, the law allows us to tell Medic= aid and KCHIP that your children are eligible for free or reduced price meals, = unless you tell us not to. Medicaid and KCHIP only use the information to identify children who may be eligible for their programs. Program officials may contact you to offer to enroll your children.  Filling= out the Free and Reduced Price School Meals Application does not automatically enroll your children in health insurance.

If you do not want us to share your information with Medi= caid or KCHIP, fill out the form below and send in (Sending in this form will not change whether your children get free or reduced price meals).

 


q=    No! I DO NOT want information from my Free and Reduce= d Price School Meals Application shared with Medicaid or the Kentucky Children's He= alth Insurance Program.

If you checked no, fill out the form below to ensure that your information is NOT shared for the child(ren) listed below:

Child's Name: ___________________________________________= School:___________________________________________        =     

Child's Name: ___________________________________________= School:___________________________________________

Child's Name: ___________________________________________= School:___________________________________________

Child's Name: ___________________________________________= School:___________________________________________

Signature of Parent/Guardian: ___________________________= ___________________Date: ______________

Printed Name:_________________= _______________________________________________________________<= /span>

Address:______________________= _______________________________________________________________<= /span>

For = more information, you may call [name] at [phone] or = e-mail at [e-mail address].  

Return this form to: [address] by [date].

SHARING INFORMATION WITH OTHER PROGRAMS<= /h1>

&nb= sp;

Dear Parent/Guardian:

To save you time and effort, the information you gave on = your Free and Reduced Price School Meals Application may be shared with other programs for which your children may qualify. For the following programs, we must have your permission to share your information. Sending in th= is form will not change whether your children get free or reduced price meals.=

 


q Yes! I DO want school officials to share information from my Free and Reduced Price School Meals Application with [name of program specific to your school]= .

q Yes! I DO want school officials to share information from my Free and Reduced Price School Meals Application with [name of program specific to your school]= .

q Yes! I DO want school officials to share information from my Free and Reduced Price School Meals Application with [name of program specific to your school]= .

 

If you checked yes to any or al= l of the boxes above, fill out the form below to ensure that your information is shared for the child(ren) listed below.  Your information will be shared on= ly with the programs you checked. 

Child's Name: ___________________________________________School:_________________________= __________________        =     

Child's Name: ___________________________________________School:_________________________= __________________

Child's Name: ___________________________________________School:_________________________= __________________

Child's Name: ___________________________________________School:_________________________= __________________

Signature of Parent/Guardian: ______________________________________________Date: ______________

Printed Name:_________________= _______________________________________________________________<= /span>

Address:______________________= _______________________________________________________________<= /span>

_________________________________________________________= ____________________________________

For = more information, you may call [name] at [phone] or e-mail at [e-mail address].

Retu= rn this form to: [address] by [date].

WE MUST CHECK YOUR APPLICATI= ON

You must send the information we need, or contact [name] by [date], or your child(ren) will stop getting free or reduced price mea= ls.

 

School: _______________________________________________________________ Date: _____= _____________

 

Dear __________________________= _________________________:

 

We are checking your Free and R= educed Price School Meals Application. Federal rules require that we do this to ma= ke sure only eligible children get free or reduced price meals. You must send = us information to prove that [name(s) of child(ren)][is/ar= e] eligible.

 

If possible, send copies, not original papers. If you do send originals, they will be sent back to you on= ly if you ask.

 

= 1. If you were receiving benefi= ts from = [State SNAP], [State KTAP] or [FDPIR]when you applied for free or re= duced price meals, or at any time since then, send us a copy of one of these:

=  

·         [State SNAP] or [State KTAP] or [FDPIR] Certification Notice that shows dates of certification.=

·         Letter from [State SNAP]= or [State KTAP] or [FDPIR] office that shows dates of certification.

·         Do not send your EBT card.

=  

= 2. If you get this letter for a homeless, migrant, or runaway child, please contact [school, homeless liaison, or m= igrant coordinator] for help.

=  

= 3. If the child is a Foster Chi= ld:

Prov= ide written documentation that verifies the child is the legal responsibility of the ag= ency or court or provide the name and contact information for a person at the ag= ency or court who can verify that the child is a foster child.   

= 4. If no one in your household receives [State SNAP] or [State KTAP] or [FDPIR] benefits:

 Send this page along with papers th= at show the amount of money your household gets from each source of income. The papers you send must show the name of the person who received the income, the date it was received, how much was received, and = how often it was received. Send information to: [address]

 

Acceptable papers include:

Jobs: Paycheck stub or pay envelope th= at shows the amount and how often pay is received; = letter from employer stating gross wages and how often you are paid; or, if you wo= rk for yourself, business or farming papers, such as ledger or tax books.=

 

Social Security, Pensions, or Retirement: Social Security retirement benefit letter, statement of benefits received, or pens= ion award notice.

 

Unemployment, Disability, or Worker’s Comp: Notice of eligibility from State employment security off= ice, check stub, or letter from the Worker’s Compensation’s office.<= o:p>

 

Welfare Payments: B= enefit letter from the [State KTAP] office.=

 

Child Support or Alimony: Court decree, agreement, or copies of checks received.

 

Other income (such as rental income): Information that shows the amount of income received, how often it is received, and the date received.

 

No income: A b= rief note explaining how you provide food, clothing ,= and housing for your household, and when you expect an income.

 

Military Housing Privatization Initiative: Letter or rental contract showi= ng that your housing is part of the Military Privatized Housing Initiative.

 

Timeframe of Acceptable Income Documentation: Please submit proof of one month’s income; you cou= ld use the month prior to application, the month you applied, or any month after t= hat.  

 

If you have questions or need h= elp, please call [name] at [phone number]. The call is free. [Toll free or reverse charge expl= anation]. You may also e-mail us at [e-mail address].

 

Sincerely,

 

[signature<= /span>]

 

 

 


Privacy Act Statement: The Richard B. Russell National School Lunch Act requires the information on this application. You do not h= ave to give the information, but if you do not, we cannot approve your child for free or reduced price meals.  = 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.

Non-Discrimination Statement: This explains what to do if you believe you have been treated unfairly. “In accordance with Federal Law and U.S. Departme= nt 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 discriminat= ion, 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 opportu= nity provider and employer.”

WE HAVE CHECKED YOUR APPLICATION

 

School: __________________________________________________________________ Date: ____________

 

Dear _________________________________:

 

We checked the information you = sent us to prove that [name(s) of child(ren)]= are eligible for free or reduced price meals and have decided that: 

q=   Your child(= ren)’s eligibility has not changed.

q=   Starting [date], your child(ren)’s eligibility for meals wi= ll be changed from reduced price to free because your income is within the free me= al eligibility limits. Your child(ren) will receive= meals at no cost.

q=   Starting [date], your child(ren)’s eligibility for meals wi= ll be changed from free to reduced price because your income is over the limit. Reduced price meals cost [$] for lunch and = [$] for breakfast.

q=   Starting [date], your child(ren) is/are no longer eligible for free or reduced price meals= for the following reason(s):

___ Records show that no one in= your household received [State SNAP] or [State TANF] benefits.  <= /p>

___ Records show that the child(ren) is/are not homeless, runaway, or migrant.

___ Your income is over the limit for free or reduced price meals.=

___ You did not provide: ______________________________________________________________= ________________________        =             &nb= sp;            =             &nb= sp;     

___ You did not respond to our request.  <= o:p>

 

Meals cost [$] for lunch and [$] for breakfast. If your household income goes down or your household size goes up, you may apply again.  If you were previously denied bene= fits because no one in the household received [State SNAP], [State TANF] or [FDPIR] benefits, you may reapply based on income eligibility.  If you did not provide proof of cu= rrent eligibility, you will be asked to do so if you reapply.

 

If you disagree with this decis= ion, you may discuss it with [name] at [phone]. You also have the right to a fair hearing. If you request a hearing by [date], your child(ren) will continue to receive free or= reduced price meals until the decision of the hearing official is made. You may req= uest a hearing by calling or writing to: [name], [addre= ss], [phone number], or [e-mail].

 

Sincerely,

 

[signature<= /span>]

 

 

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.&= nbsp; 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.”

notice to households of approval/denial = of benefits

Dear Parent/Guardian:

You applied for free or reduced-meals for the following <= span class=3DGramE>child(ren);

_______________________________= ________        &= nbsp;      ________________________________= _____ 

_______________________________= ________        _____________________________________         =

_______________________________= _________        &= nbsp;    _____________________________________ 

 

Your application was:

q&nb= sp;  Approved for free meals

q&nb= sp;  Approved for reduced price meals at $ __________ for lunch, $ ____________ for breakfast, and $ ____________ for snacks

q&nb= sp;  Denied for the following reason(s):

q Income over the allowable amoun= t

q Incomplete application because _____________________________________________________________________<= /o:p>

q Other _________________________= _______________________________________

If y= ou do not agree with the decision, you may discuss it with [school official’s name] at [phone number] or at <= strong>[e-mail address].   If you wish to review the dec= ision further, you have a right to a fair hearing. This can be done by calling or writing the following official:

NAME: ___________________________________________________________________________= __________________

ADDR= ESS: ___________________________________________________________________________= __________________

PHONE NUMBER: ____________________________________ E-MAIL _______________________= ________

Sinc= erely,

[signature<= /span>]

 

 

____= ___________________________________________________________________________= _____________________________________________

Name=         &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp; Title        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;   Date

 

____= ___________________________________________________________________________= ______________________________________________

Non-Discriminat= ion Statement: This explains what to do if you believe you have been treated unfairly. ““In accordance with Federal Law and U.S. Departme= nt 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 discriminat= ion, 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 opportu= nity provider and employer.”

 

Notice of Direct Certification

Dear Parent/Guardian:

We w= ant to let you know that the child(ren) listed below wi= ll receive  free lunches, breakfa= sts, and snacks at school because they receive [State SNAP] or = [StateKTAP].=  

Na= me of Child

Na= me of School

 

 

 

 

 

 

 

 

 

 

 

 

 

If t= here are other children in your household who aren’t listed above, they also qualify for free meals.

Plea= se contact the school your child/children attend in the following situations:<= o:p>

·= ;      =    If there are other children in your household who are not listed above and you would like them to receive free meals at school

·= ;      =    You do not want your children to have free meals

·= ;      =    You have any additional questions

[name]

[phone number]

[e-mail address]

Sinc= erely,

[signature]

 

Non-Discrimination Statement: This explains what to do if you believe you have been treated unfair= ly. “In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibit= ed from discriminating on the basis of race, color, national origin, sex, age,= or disability.  To file a complai= nt of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9= 410 or call toll free (866) 632-9992 (Voice).  Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal R= elay Service at (800) 877-8339; or (800) 845-6136 (Spanish).   USDA is= an equal opportunity provider and employer.”

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1All household= s must be notified of their eligibility status.&n= bsp; Households with children who are denied benefits must be given writt= en notification of the denial.  The notificati= on must advise the household of the reason for the denial of benefits, the rig= ht to appeal, instruction on how to appeal, and a statement that the family may re-apply for free and reduced price meal benefits at any time during the sc= hool year.  Households with childre= n who are approved for free or reduced price benefits may be notified in writing = or orally. 

 

 

 

 

 

 

 

 

 

 

 

=  

 

 

 

 

=  

 

 

 

 

 

 

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