Appendix A3. FNS-874 Form

---

Overview

874 DATA
874 Instructions

---

Sheet 1: 874 DATA

Appendix A-3. FNS-874 Form

Local Educational Agency Second Review of Applications Report

OMB APPROVED NO. 0584-0594 Expiration Date: 06/30/2017 Form: FNS-874

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it contains a valid OMB control number. The valid OMB number for this collection is 0584-0594. The time required to complete this information collection is 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

State Agency

SFA/LEA ID

SFA/LEA Name

School Year From

School Year To

1-1. Total Number of Schools in LEA

1-2. Total Number of Enrolled Students in LEA

1-3. Total number of applications (Report all applications subject to second review)

1-4. Total number of applications with changed eligibility determinations (Report all applications resulting in a changed determination due to the second review process)

1-5A. Results of Second Review by Initial Eligibility Determination Benefit Type: FREE 1. NO CHANGE

1-5A. Results of Second Review by Initial Eligibility Determination Benefit Type: FREE 2. Changed to REDUCED PRICE

1-5A. Results of Second Review by Initial Eligibility Determination Benefit Type: FREE 2. Changed to REDUCED PRICE a. Incomplete application error

1-5A. Results of Second Review by Initial Eligibility Determination Benefit Type: FREE 2. Changed to REDUCED PRICE b. Categorical eligibility error

1-5A. Results of Second Review by Initial Eligibility Determination Benefit Type: FREE 2. Changed to REDUCED PRICE c. Gross income calculation error

1-5A. Results of Second Review by Initial Eligibility Determination Benefit Type: FREE 2. Changed to REDUCED PRICE d. Other error

1-5A. Results of Second Review by Initial Eligibility Determination Benefit Type: FREE 3. Changed to PAID

1-5A. Results of Second Review by Initial Eligibility Determination Benefit Type: FREE 3. Changed to PAID a. Incomplete application error

1-5A. Results of Second Review by Initial Eligibility Determination Benefit Type: FREE 3. Changed to PAID b. Categorical eligibility error

1-5A. Results of Second Review by Initial Eligibility Determination Benefit Type: FREE 3. Changed to PAID c. Gross income calculation error

1-5A. Results of Second Review by Initial Eligibility Determination Benefit Type: FREE 3. Changed to PAID d. Other error

1-5B. Results of Second Review by Initial Eligibility Determination Benefit Type: REDUCED PRICE 1. NO CHANGE

1-5B. Results of Second Review by Initial Eligibility Determination Benefit Type: REDUCED PRICE 2. Changed to FREE

1-5B. Results of Second Review by Initial Eligibility Determination Benefit Type: REDUCED PRICE 2. Changed to FREE a. Incomplete application error

1-5B. Results of Second Review by Initial Eligibility Determination Benefit Type: REDUCED PRICE 2. Changed to FREE b. Categorical eligibility error

1-5B. Results of Second Review by Initial Eligibility Determination Benefit Type: REDUCED PRICE 2. Changed to FREE c. Gross income calculation error

1-5B. Results of Second Review by Initial Eligibility Determination Benefit Type: REDUCED PRICE 2. Changed to FREE d. Other error

1-5B. Results of Second Review by Initial Eligibility Determination Benefit Type: REDUCED PRICE 3. Changed to PAID

1-5B. Results of Second Review by Initial Eligibility Determination Benefit Type: REDUCED PRICE 3. Changed to PAID a. Incomplete application error

1-5B. Results of Second Review by Initial Eligibility Determination Benefit Type: REDUCED PRICE 3. Changed to PAID b. Gross income calculation error

1-5B. Results of Second Review by Initial Eligibility Determination Benefit Type: REDUCED PRICE 3. Changed to PAID c. Other error

1-5C. Results of Second Review by Initial Eligibility Determination Benefit Type: PAID 1. NO CHANGE

1-5C. Results of Second Review by Initial Eligibility Determination Benefit Type: PAID 2. Changed to FREE

1-5C. Results of Second Review by Initial Eligibility Determination Benefit Type: PAID 2. Changed to FREE a. Incomplete application error

1-5C. Results of Second Review by Initial Eligibility Determination Benefit Type: PAID 2. Changed to FREE b. Categorical eligibility error

1-5C. Results of Second Review by Initial Eligibility Determination Benefit Type: PAID 2. Changed to FREE c. Gross income calculation error

1-5C. Results of Second Review by Initial Eligibility Determination Benefit Type: PAID 2. Changed to FREE d. Other error

1-5C. Results of Second Review by Initial Eligibility Determination Benefit Type: PAID 3. Changed to REDUCED PRICE

1-5C. Results of Second Review by Initial Eligibility Determination Benefit Type: PAID 3. Changed to REDUCED PRICE a. Incomplete application error

1-5C. Results of Second Review by Initial Eligibility Determination Benefit Type: PAID 3. Changed to REDUCED PRICE b. Categorical eligibility error

1-5C. Results of Second Review by Initial Eligibility Determination Benefit Type: PAID 3. Changed to REDUCED PRICE c. Gross income calculation error

1-5C. Results of Second Review by Initial Eligibility Determination Benefit Type: PAID 3. Changed to REDUCED PRICE d. Other error

---

Sheet 2: 874 Instructions