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

2022-2023 Application for Free and Reduced-Price School Meals
Complete one application per household. Please use a pen (not a pencil).

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Contact information and adult signature     

Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2)

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

STEP 1

List ALL infants, children, and students up to and including grade 12 in your household (if more spaces are required for additional names, attach another sheet of paper)

STEP 2

STEP 3

STEP 4 

X   X

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

Error Prone

OFFICE USE ONLY

Eligibility: Free___   Reduced___   Denied___    
Determining Official’s Signature: ____________________________        Date: ____________________________

Case # Application   Foster Application     Directly Certified: Date of Disregard: _____________________
Income Application	  Homeless/Migrant/Runaway		   
Household Size: _______   
Total Income: __________  Per: Week   Bi-Weekly (Every 2 Weeks)  2x Month   Monthly   Annual
	
 Selected For Verification: Confirming Official’s Signature: _________________________ Date: ______________      
Follow-Up Official’s Signature: ______________________________ Date: _______________     

Today’s date

Signature of adult completing the form

“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.”

    Weekly   Bi-Weekly  2x Month  Monthly

Write only one case number in this space.

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Check if no SSN

C. Total Household Members   
     (Children and Adults)

X  X  X

A. Child Income
Sometimes children in the household earn income. Please include the TOTAL GROSS income earned by all Children Household Members listed in STEP 1 here.

Pensions/Retirement/
All Other Income

$

$

$

$

How often?

Zip

City

State

Apt #

Street Address (if available)

Daytime Phone and Email (optional)

Printed name of adult completing the form

$

$

$

$

     Weekly   Bi-Weekly  2x Month  Monthly

Public Assistance/
Child Support/Alimony

How often?

Name of Adult Household Members (First and Last)

$

$

$

$

     Weekly   Bi-Weekly  2x Month  Monthly

How often?

GROSS               Earnings from Work

How often?

	 Weekly   Bi-Weekly  2x Month  Monthly

Child GROSS income

B. All Adult Household Members (including yourself)
List only the Adult Household Members (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total GROSS income (amount before taxes and deductions) for each source in whole dollars 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.

Are you unsure what
income to include here?

Flip to the back of this application and review
the charts titled “Sources
of Income” 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 Adult Household Members Income Section. 

If you answered NO > Complete STEP 3.

If you answered YES > Write a case number here then go to STEP 4 (Do not complete STEP 3)

Case Number:

Check all that apply

Foster Child

Homeless, Migrant, Runaway

School Name

Child’s Last Name

MI

Child’s First Name

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 the definition of Homeless, Migrant or Runaway are eligible for free meals. 

$

Race (check one or more):

Sources of Income 

INSTRUCTIONS

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 American Indian or Alaskan Native          Asian          Black or African American          Native Hawaiian or Other Pacific Islander           White

Hispanic or Latino             Not Hispanic or Latino

Ethnicity (check one):

OPTIONAL

Children's Racial and Ethnic Identities

	 
Sources of Income for Children	
Type of Income	Examples	
Earnings from work	A child has a job where they earn a salary or wages.	
Social Security
-Disability payments

-Survivor Benefits	
A child is blind or disabled and receives Social Security benefits.

A parent is disabled, retired, or deceased and their child receives social security benefits.	
Income from persons outside the household	A friend or extended family member regularly gives a child spending money.	
Income from any other source	A child receives income from a private pension fund, annuity or trust.	
Sources of Income for Adults	
Earnings from Work	Public Assistance/ Alimony/Child Support	Pensions/Retirement/All Other Income	

- Salary, wages, cash bonuses

- Net income from self-employment (farm or business)

If you are in the U.S. Military:
- Basic pay and cash bonuses (do not include combat pay, FSSA, or privatized housing allowances)

-Allowances for off-base     housing, food and clothing	
- Unemployment benefits

- Workers Compensation

- Supplemental Security 
Income (SSI)

- Cash Assistance from State or local government

- Alimony payments

- Child support payments

- Veteran’s benefits

- Strike benefits
	
- Social Security (including railroad retirement and black lung benefits)

- Private Pensions or disability

- Regular income from trusts or estates

- Annuities 

- Investment Income

- Earned Interest

- Rental Income

- Regular cash payments from outside household	

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by: 1. mail:  U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, S  Washington, D.C. 20250-9410; 3. fax: (202) 690-7442; or 4. email: program.intake@usda.gov.
This institution is an equal opportunity provider.

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, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

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 children’s eligibility for free or reduced-price meals.