INSTRUCTIONS FOR APPLYING
A HOUSEHOLD MEMBER IS ANY CHILD OR ADULT LIVING WITH YOU.
IF YOUR HOUSEHOLD RECEIVES BENEFITS FROM [State SNAP], [State TANF], OR [THE FOOD DISTRIBUTION PROGRAM ON
INDIAN RESERVATIONS (FDPIR)], FOLLOW THESE INSTRUCTIONS:
Part 1: List only household members and the name of each child’s school (if known).
Part 2: List the case number for any household member (including adults) receiving [State SNAP],[State TANF], or [FDPIR] benefits.
Part 3: Skip this part.
Part 4: Sign the form. The last four digits of a Social Security Number are not necessary.
Part 5: Answer this question if you choose.
Turn the form in to Barbara Bishop/Lunch Program Coordinator (or drop off in deposit slot near the front office) at your school.
IF NO ONE IN YOUR HOUSEHOLD GETS [State SNAP], [State TANF], OR [FDPIR] BENEFITS AND IF ANY CHILD IN YOUR
HOUSEHOLD IS HOMELESS, A MIGRANT OR RUNAWAY, OR IN HEAD START FOLLOW THESE INSTRUCTIONS:
Part 1: List all household members and the name of each child’s school (if known). If any child you are applying for is homeless, migrant, in Head
Start or a runaway check the appropriate box and call Karen Kieffer/Guidance.
Part 2: Skip this part.
Part 3: Complete only if a child in your household isn’t eligible under Part 1. See instructions for All Other Households.
Part 4: Sign the form. The last four digits of a Social Security Number are not necessary if you didn’t need to fill in Part 3.
Part 5: Answer this question if you choose.
Turn the form in to Barbara Bishop/Lunch Program Coordinator (or drop off in deposit slot near the front office) at your school.
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: Sign the form. The last four digits of a Social Security Number are not necessary.
Part 5: Answer this question if you choose.
Turn the form in to Barbara Bishop/Lunch Program Coordinator (or drop off in deposit slot near the front office) at your school.
If some of the children in the household are foster children:
Part 1: List all household members and the name of each child’s school (if known). For any person, including children, with no income, you must
check the “No Income” box. Check the box for each foster child. If any child you are applying for is homeless, migrant, in Head Start or a runaway
check the appropriate box and if you have questions call your school.
Part 2: Skip this part.
Part 3: Complete only if a child in your household isn’t eligible under Part 1. See instructions for All Other Households.
Part 4: 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 5: Answer this question if you choose.
Turn the form in to Barbara Bishop/Lunch Program Coordinator (or drop off in deposit slot near the front office) at your school.
ALL OTHER HOUSEHOLDS, INCLUDING WIC HOUSEHOLDS, FOLLOW THESE INSTRUCTIONS:
Part 1: List all household members and the name of each child’s school (if known). For any person, including children, with no income, you must
check the “No Income” box. If any child you are applying for is homeless, migrant, Head Start, a foster child or a runaway check the appropriate
box and call Karen Kieffer/Guidance.
Part 2: Skip this part.
Page 1 of 4
Part 3: Follow these instructions to report total household income from this month or last month.
Section 1Name: List all household members with income.
Section 2
o Gross Income and How Often It Was Received: For each household member listed in section 1, list each type of income
received for the month. You must tell us how often the money is receivedweekly, every other week, twice a month or
monthly.
o 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.
o Income received from welfare, child support, and alimony: List the amount each person received.
o Income received from retirement benefits, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA
benefits), and disability benefits: List the amount each person received.
o 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 benefits from WIC, Federal education 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.
Your children may qualify for free or reduced-price meals if your household income falls at or below the limits on this chart:
FEDERAL ELIGIBILITY INCOME CHART For School Year 2019-2020
Household size
Yearly
Monthly
Weekly
1
23,107
1,926
445
2
31,284
2,607
602
3
39,461
3,289
759
4
47,638
3,970
917
5
55,815
4,652
1,074
6
63,992
5,333
1,231
7
72,169
6,015
1,388
8
80,346
6,696
1,546
Each additional person:
+8,177
+682
+158
Part 4: 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).
The information contained within this application may be shared with other Federal/Local health programs for which your child(ren) may
qualify, however your permission is required. This will not affect your eligibility for school meals. May school officials share the
information within this application with other programs? Check the appropriate box.
Part 5: Answer this question if you choose.
Turn the form in to Barbara Bishop/Lunch Program Coordinator (or drop off in deposit slot near the front office) at your school.
Page 2 of 4
2019-2020
FREE AND REDUCED-PRICE SCHOOL MEALS FAMILY APPLICATION
PART 1. ALL HOUSEHOLD MEMBERS ** RETURN THIS APPLICATION TO YOUR CHILD’S SCHOOL**
Place a check in the box below if child is a foster, homeless, migrant, Place a
Names of all household members
runaway, or Head Start child. If each child attending school is a foster, check in the
Student ID
(First, Middle Initial, Last)
homeless, runaway, migrant or in Head Start, skip to part 4 to sign this form. box if NO
Foster Homeless Migrant Runaway Head Start income
PART 2. BENEFITS
IF ANY MEMBER OF YOUR HOUSEHOLD RECEIVES [State SNAP], [FDPIR] OR [State TANF Assistance], PROVIDE THE NAME AND CASE NUMBER FOR
THE PERSON WHO RECEIVES BENEFITS AND SKIP TO PART 4. IF NO ONE RECEIVES THESE BENEFITS, SKIP TO PART 3.
NAME:_____________________________________________ PROGRAM NAME _____________________ CASE NUMBER
: (NOT EBT CARD NUMBER)_________________________________
PART 3. TOTAL HOUSEHOLD GROSS INCOME (BEFORE DEDUCTIONS). List all income on the same line as the person who receives it. Check
the box for how often it is received. RECORD EACH INCOME ONLY ONCE.
1. NAME
2. GROSS INCOME AND HOW OFTEN IT WAS RECEIVED
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PART 4. SIGNATURE AND LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (ADULT MUST SIGN)
An adult household member must sign the application. If Part 3 is completed, the adult signing 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” box. (See Statement on the back of this page.)
I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds
based on the information 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. I understand my child’s eligibility status may be shared as allowed by law.
Signature: ____________________________________ Printed name:_______________________________________________ Date: _______________________________________
Address:___________________________________________________________________________________________ Phone Number: ___________________________________________
Email:______________________________________________________ City:____________________________________ State:___________ Zip Code:__________________________
Last four digits of Social Security Number: * * * - * * - ___ ___ ___ ___ I do not have a Social Security Number
The information contained within this application may be shared with other Federal/Local health programs for which your child(ren) may qualify, however your
permission is required. This will not affect your eligibility for school meals. May school officials share the information within this application with other
programs No Yes Child(ren) may also qualify for free or low-cost health and dental insurance with Florida KidCare. Apply at floridakidcare.org or call 1-
888-540-5437.
PART 5. CHILDREN’S ETHNIC AND RACIAL IDENTITIES (OPTIONAL)
Choose one ethnicity:
Hispanic/Latino
Choose one or more (regardless of ethnicity):
Asian American Indian or Alaska Native Black or African American
Not Hispanic/Latino White Native Hawaiian or other Pacific Islander
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*****DO NOT FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY*****
Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24 Monthly x 12
Total Income: ____________________ Per: Week, Every 2 Weeks, Twice A Month, Month, Year Household size: ________
Categorical Eligibility: ______ Eligibility: Free_______ Reduced_______ Denied______ Date Withdrawn:_________________________________
Reason for denial or withdrawal: _________________________________________________________________ Check if Error Prone Application
Determining Official’s Signature: __________________________________________________________________ Date: __________________________________________
Confirming Official’s Signature: ____________________________________________________________________ Date: _________________________________________
Verifying Official’s Signature: _______________________________________________________________________ Date: _________________________________________
The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do
not, we cannot approve your child for free or reduced-price meals. You must include the last four digits of the social security number of the adult
household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster
child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution
Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member
signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced-
price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education,
health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law
enforcement officials to help them look into violations of program rules.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its
Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based
on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or
funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape,
American Sign Language, etc.), should contact the Agency (State or local) where they applied for benets. Individuals who are deaf, hard
of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program
information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online
at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in
the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your
completed form or letter to USDA by:
mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue,
SW
Washington, D.C. 20250-9410
fax: (202) 690-7442; or
email: program.intake@usda.gov.
This institution is an equal opportunity provider.
Date of
Contact
Staff
Initials
Name of Household Member
Contacted
Detailed Information Received
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