Appendix D11. Household Interview Appointment Reminder Letter

APPENDIX D11. HOUSEHOLD INTERVIEW APPOINTMENT REMINDER LETTER
OMB Number: 0584-0530
Expiration Date: XX/XX/XXXX

Dear ,
Thank you for agreeing to be part of the National School Meals Study (NSMS). We owe our success to your help.
A NSMS Study interviewer is scheduled to call on
to discuss your experience completing an application for to participate in the National
School Breakfast and Lunch program. If you are not able to keep this appointment, please let us know as soon as
possible.
A blank copy of the meal application is enclosed and will be referenced during the interview.
As a reminder, you will receive a thank you gift card of $20, once you finish the interview.
Please do not wait to call us at 1-855-820-6138 or email us at [email protected] if you have any questions
or if your appointment needs to be changed. Thank you for your support!
Sincerely,

Enclosures:

Copy of Free and Reduced Meals Application

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 0584-0530. The time required to complete this information collection is estimated to average 5
minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data
needed, and complete and review the collection of information.

APPENDIX D11. HOUSEHOLD INTERVIEW APPOINTMENT REMINDER LETTER

Enclosure: Copy of Free and Reduce Meals Application
Please note that each individual Household Interview participant will be sent a copy of their
specific State’s application.
Included is the State of Maryland’s application as a sample.

APPENDIX D11. HOUSEHOLD INTERVIEW APPOINTMENT REMINDER LETTER
FREDERICK COUNTY PUBLIC SCHOOLS
Food and Nutrition Services
33 Thomas Johnson Drive, Frederick, MD 21702
301-644-5061 food.service@fcps.org

AUGUST 2015

Dear Parent/Guardian:
Children need healthy meals to learn. Frederick County Public Schools offer healthy meals every school day. Your children may qualify for free
or reduced-price breakfast and lunch meals (“MEALS”).
1.

DO I NEED TO FILL OUT AN APPLICATION FOR EACH CHILD? No. Complete ONE Meal Benefit Application for ALL children
in your household. We cannot approve an application that is not complete. Fill out all required information. Return the completed application to
your child’s school or Food and Nutrition Services, FCPS, 33 Thomas Johnson Dr., Frederick, MD 21702.

2.

WHO CAN RECEIVE FREE MEALS? All children in households receiving benefits from the Food Supplement Program (FSP) or
Temporary Cash Assistance (TCA) can receive free meals regardless of your income. Also, your children can receive free meals if your
household’s gross income is within the free limits on the Federal Income Eligibility Guidelines.

3.

CAN FOSTER CHIDLREN RECEIVE 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 household is eligible for free meals regardless of income.

4.

CAN HOMELESS, MIGRANT, RUNAWAY AND HEADSTART CHILDREN RECEIVE FREE MEALS? Yes. If you have NOT
been told that your child(ren) will receive free school meals this year, complete the application. You may also call your school counselor,
community liaison, or homeless coordinator to ask about benefits.

5.

WHO CAN RECEIVE REDUCED-PRICE MEALS? Your children can receive low cost meals if your household income is within the
reduced-price limits on the Federal Income Eligibility Guidelines.

6.

SHOULD I FILL OUT AN APPLICATION IF I RECEIVED A LETTER THIS SCHOOL YEAR SAYING MY CHILDREN
ARE APPROVED FOR FREE MEALS? NO, YOU DO NOT NEED TO COMPLETE AN APPLICATION. CALL 301-644-5061 IF
YOU HAVE QUESTIONS.

7.

MY CHILD’S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT ANOTHER ONE? Yes. Your child’s
application is only good for that school year and for the first few days of this school year. You must submit a new application unless you were
told that your child is eligible for the new school year.

8.

I GET WIC. CAN MY CHILD(REN) GET FREE MEALS? Children in households participating in WIC may be eligible, based on
income for free or reduced-price meals. Please fill out an application.

9.

WILL THE INFORMATION I GIVE BE CHECKED? Yes, your information may be checked and we may ask for written proof.

10. IF I DO NOT QUALIFY NOW, MAY I APPLY LATER? Yes, you may apply at any time during the school year.
11. WHAT IF I DISAGREE WITH THE DECISION ABOUT MY APPLICATION? You may contact Food and Nutrition
Services, 301-644-5061 or food.service@fcps.org. You may also ask for a hearing by calling or writing to: Leslie Pellegrino, Executive
Director, Fiscal Services, FCPS, 33 Thomas Johnson Dr., Frederick, MD 21702, phone 301-644-5061.
12. 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 qualify for free or reduced-price meals.
13. WHO SHOULD I INCLUDE AS MEMBERS OF MY HOUSEHOLD? Your household includes all those living as one economic unit,
related or not (such as grandparents, other relatives, foster children or friends).
14. 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.
15. 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. However, if your housing is part of the Military Housing Privatization Initiative, do not include your
housing allowance as income.
16. MY SPOUSE IS DEPLOYED TO A COMBAT ZONE. IS HER COMBAT PAY COUNTED AS INCOME? No, if the combat pay is
in addition to basic pay because of deployment, and it was not received before they were deployed, combat pay is not counted as income.
17. MY FAMILY NEEDS MORE HELP. ARE THERE OTHER PROGRAMS WE MIGHT APPLY FOR? For information and referral
for the Food Supplement Program, Temporary Cash Assistance, and medical programs call 1-800-332-6347.
If you have other questions or need help, call 301-644-5061.
Sincerely,

Robert D. Kelly
Sr. Manager, Food and Nutrition Services

APPENDIX D11. HOUSEHOLD INTERVIEW APPOINTMENT REMINDER LETTER

AUGUST 2015
INSTRUCTIONS FOR APPLYING
To apply for free or reduced-price meals, complete the form using the instructions below. Sign the form and return it to the school or Food and
Nutrition Services. If you need help, call 301-644-5061.
STEP 1 – STUDENT INFORMATION - ALL HOUSEHOLDS COMPLETE
List the enrolled child(ren’s) first and last name, student id number and school. Indicate if a foster child, homeless, migrant, runaway, or
in Head Start, Early Head Start or Even Start by checking the box. If ALL students listed are foster, homeless, migrant, runaway, or in
Head Start, Early Head Start or Even Start, skip to Step 4.
STEP 2 – CASE NUMBER
If any member of your household receives benefits from the Food Supplement Program (FSP) or Temporary Cash Assistance (TCA),
write the case number in the space provided and skip to Step 4.
STEP 3 – NAMES OF ALL HOUSEHOLD MEMBERS AND GROSS INCOME
1. List the first and last name of everyone in your household, whether they receive income or not. Your household includes all those living
as one economic unit. Include yourself, all children living with you, including foster children and any other person living in your
household, related or not. List each type of income received last month and how often it is received. You must indicate how much in
whole dollars, and how often received (weekly, bi-weekly, twice a month, monthly, yearly). If a household member has no
income—write ‘0’ in the income box.
2. Report all income as gross income. Gross income is the amount earned before taxes and other deductions. This is not the same as takehome pay. Gross income includes income from unemployment benefits, Worker’s Compensation, Supplemental Security Income and
Veteran’s Benefits, Social Security, private pensions or disability, strike benefits, income from trusts or estates, annuities, investment
income, earned interest, rental income and regular cash payments from outside household. For self-owned business, farm, or rental
income, report income as net income.
3. If you are in the Military Housing Privatization Initiative, do not include your housing allowance as income. Do not include combat
pay.
4. Indicate the total number of household members in the space provided.
5. The form must have the last four digits of the Social Security Number of the primary wage earner or adult who signs unless the adult
does not have a Social Security Number. If the adult does not have a Social Security Number, check the box. The last four digits of the
Social Security Number are not needed if you listed a FSP or TCA case number, or if you are only applying for foster children.
STEP 4 – SIGNATURE - ALL HOUSEHOLDS COMPLETE
All forms must have the signature of an adult household member.
STEP 5 – RACIAL/ETHNIC IDENTITY
You are not required to answer this question to get meal benefits. This information will help ensure that everyone is treated fairly.
STEP 6 – SHARING INFORMATION WITH OTHER PROGRAMS
Check the boxes to indicate your preference for sharing or not sharing application information with the programs indicated. Your decision
will not change whether your children get free or reduced-price meals.
Federal Income Eligibility Guidelines

Household Size
1
2
3
4
5
6
7
8
For each additional
family member add:

Year
$21,775
29,471
37,167
44,863
52,559
60,255
67,951
75,647

Month
$1,815
2,456
3,098
3,739
4,380
5,022
5,663
6,304

Week
$419
567
715
863
1,011
1,159
1,307
1,455

$7,696

$642

$148

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 are not required when you are only applying for
foster children, or you list a Food Supplement Program or Temporary Cash Assistance case
number, 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.

Nondiscrimination Statement: The U.S Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex,
gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or
protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.)
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found at http://www.ascr.usda.gov/complaint_filing_cust.html or at any USDA office, or
call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture,
Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov.
Individuals who are deaf, hard of hearing 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.

The Maryland State Department of Education does not discriminate on the basis of age, ancestry/national origin, color, disability, gender identity/expression, marital status, race, religion, sex,
or sexual orientation in matters affecting employment or in providing access to programs and activities and provides equal access to the Boy Scouts and other designated youth groups. For
inquiries related to Department policy, please contact: Equity Assurance and Compliance Office, Office of the Deputy State Superintendent for Finance and Administration, Maryland State
Department of Education 200 W. Baltimore Street - 6th Floor Baltimore, Maryland 21201-2595 410-767-0426 – voice 410-767-0431 – fax 410-333-6442 - TTY/TDD.

APPENDIX D11. HOUSEHOLD INTERVIEW APPOINTMENT REMINDER LETTER

AUGUST 2015

2015-2016 Meal Benefit Application for Free and Reduced-Price School Meals
Complete ONE Application per Household
For More Information, read Instructions for Applying or call 301-644-5061 – Remove Cover Sheet Before Submitting

Step 1

List all enrolled children (if more spaces are required for additional names, attach another sheet of paper).

Children in Foster Care and children who meet the definition of Homeless, Migrant, Runaway, Head Start, Early Head Start or Even Start are eligible for free meals. If all enrolled children meet the
definition of Homeless, Migrant, Runaway, Head Start, Early Head Start or Even Start, complete Step 1 then skip to Step 4.

First and Last Names (as Registered at the
School) of All ENROLLED Children

Check () if foster child, homeless, migrant, runaway, in Head
Start, Early Head Start or Even Start
Foster Child

Homeless

Runaway

Head Start
Early Head Start

School Name

Even Start

Do any Household Members (including you) currently participate in one or more of the following assistance programs: Food Supplement Program (FSP) or
Temporary Cash Assistance (TCA)? Circle one: Yes
No

Step 2

If you answered NO, complete Step 3.
If you answered YES, provide a case number then go to Step 4

Step 3

Migrant

Case
Number:

Report Income for ALL Household Members (skip this step if you answered YES to Step 2)

All Household Members (including yourself) – List all Household Members (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report
total income and how often 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 not income to report.
How often = Weekly, Bi-Weekly, Twice a Month, Monthly, Yearly.

Earnings from Work

First and Last Names of ALL Household Members

Income

Income

How Often?

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

Total Household Members (Children and Adults):

Step 4

How Often?

Child Support, Alimony,
Public Assistance

Pensions, Retirement, Other
Income
Income

How Often?

Check if
No SSN:

Contact Information and Adult Signature

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.
Printed Name:

Signature:

Street Address:
Date:

Step 5

Phone #:
OPTIONAL: Children’s Racial and Ethnic Identities

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.
Ethnicity (Check One):

Race (Check one or more):

Hispanic or Latino
Not Hispanic or Latino

Step 6

American Indian or Alaskan Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

White

Sharing Information with Other Programs

The eligibility status of your children may be used for other authorized purposes, shared with local Title I officials, and used for National Assessment of Educational Progress analyses. Your family may also be eligible to
receive benefits under FSP or the Women, Infants, and Children (WIC) Program.
To share your information with these programs, we must have your permission. Your decision will not change whether your children receive free or reduced-price meals. If you want information shared with FSP or WIC,
check (√) the YES box below. You may be contacted about submitting an application for the FSP or WIC.
YES, I want information shared from the Free and Reduced-Price
FSP
Meal Benefit Application with

and/or

WIC

Children eligible for free or reduced-price school meals may also be able to get free or low-cost health insurance through Medicaid or the MD Children’s Health Insurance Program (MCHIP). The law allows us to inform
Medicaid and MCHIP that your children are eligible for free or reduced-price meals, unless you say NO. Your decision will not change whether your children receive free or reduced-price meals. If you do NOT want
information shared with Medicaid or MCHIP, check (√) the NO box:
NO

DO NOT FILL OUT THIS SECTION. FOR OFFICE USE ONLY
Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly x 12
Total Income (Children and Adults): $
Eligibility:
Determining Official's Signature and Date Determined:
Confirming Official's Signature and Date Determined:
Verifying Official's Signature and Date Determined:

Weekly

Every 2 Weeks

Twice a Month

Monthly

Free

Categorically
Eligible

Reduced

Paid

Yearly

</pre><Table class="table"><tr><Td>File Type</td><td>application/pdf</td></tr><tr><Td>Author</td><td>April Fales</td></tr><tr><Td>File Modified</td><td>2017-03-22</td></tr><tr><Td>File Created</td><td>2017-01-10</td></tr></table></div></div></div><hr>
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