NSLP Verification II - SLT IC (IC 1 of 2)

Attachment A – Modified Verification Letter

Dear [Susan],

[Mary Jones, Tom Jones, and Steven Jones] were approved for free/reduced price meals a little while ago.

But there is one last step – we need to verify your application. Each year we ask different households for proof to make sure that only eligible children receive free/reduced price meals.

Send the information we request on page 2 by [Oct 16], or your child(ren) will stop receiving free/reduced price meals.

If you have any questions or need help, please contact [Juanita Price] at the [toll free number] [(xxx)-xxx-xxxx] or via [email].

Sincerely,

[Signature]

The documents you need to submit are explained on page 2 

Name

[Director, Child Nutrition Services]

[School District]

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0524. The time required to complete this information collection is estimated to average two hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Non-Discrimination Statement: This explains what to do if you believe you have been treated unfairly.

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, religious creed, disability, age, political beliefs, 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, (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: [email protected]. This institution is an equal opportunity provider.

The Richard B. Russell National School Lunch Act requires the information we are requesting. While providing the requested information is voluntary we cannot approve your children for free or reduced price meals if you do not provide the information. 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. Pursuant to Section of 7 of the Privacy Act, disclosure of your Social Security number is not required. We do not need and are not requesting any Social Security numbers that may appear on documents you submit.

How to Prove Eligibility

Please provide ONE of the following by [Oct 16]. Documents can be dated from the time of application, one month prior to application, or any time since:

1.		[SNAP], [TANF] or [FDPIR]	Send your [SNAP], [TANF], or [FDPIR] Certification Notice (the document that told you that you were approved for benefits) or a letter from the same office that shows dates of certification. Do not send your EBT Card!
		Foster child	Send documentation from a State child welfare agency or court. Or provide the name and contact information for a person at the agency or court who can verify that the child is a foster child.
		Homeless, Migrant, Runaway child	Contact [school, homeless liaison, or migrant coordinator] at (xxx)-xxx-xxxx].
	OR
2.		Proof of household income	Send documents for each income source your household receives showing the amount of income, name of the person who received the income, the date it was received, and how often it was received. Examples of acceptable documents are listed below.

Send this information via ONE of the following methods by [Oct 16].

OR

OR

T ake pictures of the requested documents with your phone/camera and email them to [e-mail]. Include a picture of the first page of this letter.

Mail documents along with the first page of this letter to [mailing address] using the pre-paid envelope provided. We will send back originals.

Come in person to the office located at [address] to drop off the documents. Please bring this letter with you.

Acceptable Documents

• Jobs: Paycheck stub or pay envelope. If the stub or envelope does not list how often you receive pay, please include a letter from your employer stating gross (total) wages and how often you are paid; or, if you work for yourself, please include business or farming papers, such as ledger books or last year’s tax return.

• Social Security, Pensions, or Retirement: Social Security retirement benefit letter, statement of benefits received, or pension award notice.

• Unemployment, Disability, or Worker’s Compensation: Notice of eligibility from State employment security office, check stub, or letter from the Worker’s Compensation office.

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

• All Other Income: Information that shows the amount of the income, name of the person who received the income, the date it was received, and how often it was received.

• No Income: A brief note explaining how you provide for your household expenses, and when you expect an income.

• Military Housing Privatization Initiative: Letter or rental contract showing that your housing is part of the Military Privatized Housing Initiative.