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Schaumburg School District 54 participates in the Illinois

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Dear Parent/Guardian:
Schaumburg School District 54 participates in the Illinois Free Lunch Program. Qualified students may receive
free lunch and milk. Your student's consumable fee will also be waived if you qualify for free lunch by
application. Your child(ren) may qualify for free milk/lunch if your household income falls within or below the
Federal Income Guidelines below.
Federal Income Eligibility Guidelines (Effective from July 1, 2021 to June 30, 2022)
Free Meals (130% Federal Poverty Guidelines)
Household Size Annual Monthly
Twice Per
Month
Every Two
Weeks
Weekly
1
16,744
1,396
698
644
322
2
22,646
1,888
944
871
436
3
28,548
2,379
1,190
1,098
549
4
34,450
2,871
1,436
1,325
663
5
40,352
3,363
1,682
1,552
776
6
46,254
3,855
1,928
1,779
890
7
52,156
4,347
2,174
2,006
1,003
8
58,058
4,839
2,420
2,233
1,117
For each additional family member, add
5,902
492
246
227
114
Here are some questions you may have about applying:
1. Do I need to fill out an application for each child? No. Complete the application to apply for free milk
and/or lunch. Use one Household Eligibility Application for all students in your household per district. We cannot
approve an application that is not complete, so be sure to fill out all required information. Return the completed
application to your child's school.
2. Who can get free milk and/or lunch? All children in households receiving benefits from Supplemental
Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) and/or are foster
children that are under the legal responsibility of a foster care agency or court are eligible for free milk/lunch
regardless of your income. Also, your children can get free lunches if your household's gross income is within
the free limits on the Federal Income Eligibility Guidelines. Children who meet the definition of homeless,
runaway, or migrant also qualify for free milk/lunch.
3. A member of my household received snap or TANF benefits. The school sent a letter stating that my
child is automatically approved for free milk/lunch based on direct certification. Do I need to do
anything more to ensure that my child receives free milk/lunch? No. You do not need to do anything more
to receive free milk/lunch for your child. If you have students not listed on the letter, contact the school
immediately. If you do not wish to receive the free milk or lunch, you should notify school personnel
immediately.
4. My child's application was approved last year. Do I need to fill out another one this year? 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.
5. I Get WIC. (Women, Infants, and Children) Can my child(ren) get free milk/lunch? Children in
households participating in WIC be eligible for free milk/lunch. Please fill out the enclosed application.
524 East Schaumburg Road
Schaumburg, Illinois 60194
Phone
847/357-5027
FAX
847/357-5010
TTY
847/357-5076
http://sd54.org
Andrew D. DuRoss
Superintendent
of Schools
6. How do I know if my children qualify as homeless, migrant, 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 contact your school.
7. Will the information I give be checked? Yes. We may also ask you to send written proof.
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 meals if
the household income drops below the income limit.
9. What if I disagree with the school's decision about my application? If you do not agree with the decision
on your application or with the results of the verification, please contact Ric King at (847) 357-5011. You may
also request a fair hearing. If you request a hearing, you must do so in writing and send your request to: Nick
Myers, Associate Superintendent, School District 54, 524 E. Schaumburg Road, Schaumburg, IL 60194.
10. May I apply if someone in my household is not a U.S. citizen? Yes. You or your child(ren) do not have
to be U.S. citizens to apply.
11. Who should I include as members 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 and expenses.
You must include yourself and all children living with you. If you live with people who are economically
independent (for example, people who you do not support, who do not share income with you or your children,
and who pay a pro-rated share of expenses), do not include them.
12. What if my income is not always 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.
13. 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 be
counted as zeroes. Please be careful when leaving income fields blank, as we will assume you meant to do so.
14. 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, 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.
15. My family needs more help. Are there other programs we might apply for? To find out how to apply for
SNAP, TANF or other assistance benefits, contact your local Department of Human Services office or call (800)
843-6154 (voice) or (800) 447-6404 (TTY).
Sincerely,
Claudia Nicholas
847-357-5021
ISBE 68-13 Special Milk/IL Free (5/21)
INSTRUCTIONS FOR APPLYING – COMPLETE ONE APPLICATION PER HOUSEHOLD PER SCHOOL DISTRICT
IF YOUR HOUSEHOLD RECEIVES SNAP OR TANF BENEFITS, FOLLOW THESE INSTRUCTIONS AND RETURN THE COMPLETED FORM TO YOUR SCHOOL:
Part 1: List all household members, school and grade for each student, and a SNAP or TANF case number for any household member including adults receiving such
benets. (Attach another sheet of paper if necessary.) .
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 & 6: Contact Information, and Children’s Racial and Ethnic Identities: Answer these questions if you choose to. (Optional)
IF NO ONE IN YOUR HOUSEHOLD GETS SNAP OR TANF BENEFITS AND IF ANY CHILD IN YOUR HOUSEHOLD IS HOMELESS, A MIGRANT OR RUNAWAY OR
HEAD START/EVEN START, FOLLOW THESE INSTRUCTIONS AND RETURN THE COMPLETED FORM TO YOUR SCHOOL:
Part 1: List all household members and the name of school for each child.
Part 2: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your school.
Part 3: Complete only if a child in your household isn’t eligible under Part 2. See instructions for All Other Households.
Part 4: Sign the form. Only if part 3 is completed, please include the last four digits of a Social Security Number. (
or ma
rk the box if s/he doesn’t have one).
Part 5 & 6: Contact Information, and Children’s Racial and Ethnic Identities: Answer these questions if you choose to. (Optional)
IF YOU ARE APPLYING FOR A FOSTER CHILD, FOLLOW THESE INSTRUCTIONS AND RETURN THE COMPLETED FORM TO YOUR SCHOOL:
If all children in the household are foster children that are the legal responsibility of a foster care agency or court:
Part 1: List all foster children and the school name for each child. Check the “Foster Child” box for each 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 & 6: Contact Information, and Children’s Racial and Ethnic Identities: Answer these questions if you choose to. (Optional)
If some of the children in the household are foster children that are the legal responsibility of a foster care agency or court:
Part 1: List all household members and the name of school for each child. Check the “Foster Child” box for each foster child.
Part 2: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your school.
Part 3: 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 nd 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 benets (VA benets), and disability
benets. Under All Other Income, list Worker’s Compensation, unemployment or strike benets, 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 benets 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 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 & 6: Contact Information, and Children’s Racial and Ethnic Identities: Answer these questions if you choose to. (Optional)
ALL OTHER HOUSEHOLDS INCLUDING MEDICAID AND WIC HOUSEHOLDS, FOLLOW THESE INSTRUCTIONS:
Part 1: List all household members and the name of school for each child.
Part 2: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your school.
Part 3: 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 nd 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 benets (VA benets), and disability
benets. Under All Other Income, list Worker’s Compensation, unemployment or strike benets, 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 benets 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 benets. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income.
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 & 6: Contact Information, and Children’s Racial and Ethnic Identities: Answer these questions if you choose to. (Optional)
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, 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 identier 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 benets for their programs, auditors for program
reviews, and law enforcement ofcials 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, ofces, 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 benets. 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 le a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/
complaint_ling_cust.html, and at any USDA ofce, 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) mail: U.S. Department of Agriculture, Office 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.
ISBE 68-03 NSSTAP Application Instructions (5/21)
2. Homeless, Migrant, Runaway, or Head Start (Categorically eligible)
Homeless Migrant Runaway Head Start
______________________________________________________________________ __________________
Signature of Your School Homeless Liaison, Migrant Coordinator, or Head Start Director Date
3. Total Household Gross Income (before deductions) You must tell us how much and how often.
NAMES
(LIST ALL HOUSEHOLD MEMBERS
WITH INCOME)
GROSS INCOME AND HOW OFTEN IT WAS RECEIVED (Example: $100/month; $100 /twice a month; $100/every other week; $100/week)
Earnings From Work
(Before Deductions)
Welfare, Child
Support, Alimony
Pensions, Retirement,
Social Security
Worker’s Comp., Unemploy-
ment, SSI, etc. (All other income)
Amount How often? Amount How often? Amount How often? Amount How often?
i.
$ $ $ $
ii.
$ $ $ $
iii.
$ $ $ $
iv.
$ $ $ $
v.
$ $ $ $
4. Signature and Social Security Number (Adult must sign)
An adult household member must sign the application. If Part 3 is completed, the adult
signing the form must also list the last four digits of his or her social security number or
mark the I do not have a social security number box.
__ __ __ - __ __ - __ __ __ __
Social Security Number
I do not have a social
security number.
I certify (promise) all information on this application is true and all income is reported. I understand the school will get Federal funds based on the information I give. I understand school
ofcials may verify (check) the information. I understand if I purposely give false information, my children may lose meal benets and I may be prosecuted.
______________________________ _____________________________________________________ _________________________________________________________
Date Printed Name of Adult Household Member Signature of Adult Household Member
5. Contact Information (Optional)
________________________________________ ____________________________________________ ____________________________________________________________
Work Telephone Number (Include Area Code) Home Telephone Number (Include Area Code) Home Address (Number, Street, City, State, Zip Code)
6. Children’s Racial and Ethnic Identities (Optional)
Mark one ethnic identity:
Hispanic/Latino
Not Hispanic/Latino
Mark one or more racial identities:
Asian Black or African American Native Hawaiian or Other Pacic Islander
White American Indian or Alaska Native
NAMES OF ALL HOUSEHOLD MEMBERS
First, Middle Initial, Last School Name Grade
SNAP OR TANF CASE NUMBER ONLY Skip to Part
4 if you list a SNAP or TANF case number. At least one SNAP/
TANF must be provided below. If you receive Medicaid and were
not directly certied for free meals, you MUST apply based on
household size and income.
* A foster child is the legal responsibility of a welfare agency or court.
APPLICATION FOR FREE MILK/MEAL AND REDUCED-PRICE MEALS—Complete One Application Per Household Per School District. Instructions on back.
SCHOOL USE ONLY
1. All Household Members (Attach another sheet of paper if necessary.)
Check if Error Prone Application
(for Student only)
A. B.
C. D. E.
(for Student only)
Check if
Foster
Child*
x x x x x
68-03 School Year 2021-2022 NSSTAP (5/21)
Schaumburg Community Consolidated School District 54
524 East Schaumburg Road, Schaumburg, IL 60194
Application for Illinois Free Lunch Program 2021-2022 School Year
To apply for free milk/lunch, complete this application, sign and return the application to the school.
If you need help, please call 847-357-5021
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Schaumburg School District 54 participates in the Illinois

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Completed 13 August 2021

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