Household - 7 CFR 245

Attachment J: Prototype Household Application for Free and Reduced Price School
Meals
This information is being collected from School food authorities and schools. This is a revision of a currently
approved information collection. The Richard B. Russell National School Lunch Act (NSLA) 42 U.S.C. § 1758, as
amended, authorizes the National School Lunch Program (NSLP). This information is required to administer and
operate this program in accordance with the NSLA. Under the Privacy Act of 1974, any personally identifying
information obtained will be kept private to the extent of the law. 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
0584-0026. The time required to complete this information collection is estimated to average 6 minutes per
response. The burden consists of the time it takes for households to complete their application. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 1320
Braddock Place, Alexandria, VA 22314, ATTN: PRA (0584-0026). Do not return the completed form to this address.

Prototype Household Application for Free and Reduced Price School Meals

OMB Control Number 0584-0026 Expiration Date: X/XX/20XX

Complete one application per household. Please use a pen (not a pencil).

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

Definition of Household
Member: “Anyone who is
living with you and shares
income and expenses, even
if not related.”

Child’s First Name

MI

Child’s Last Name

Student?
Yes
No

Grade

Children in Foster care and
children who meet the
definition of Homeless,
Migrant or Runaway are
eligible for free meals. Read
How to Apply for Free and
Reduced Price School
Meals for more information.

STEP 2

Foster
Child

Homeless,
Migrant,
Runaway

Check all that apply

STEP 1

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

> Go to STEP 3.

If YES >

Case Number:

Write a case number here then go to STEP 4 (Do not complete STEP 3)

Write only one case number in this space.

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

A. Child Income

Child income

Sometimes children in the household earn or receive income. Please include the TOTAL income received by all
Household Members listed in STEP 1 here.
Are you unsure what
income to include here?
Flip the page and review
the charts titled “Sources
of Income” for more
information.

Bi-Weekly 2x Month

Monthly

$

B. All Adult Household Members (including yourself)

List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total gross income (before taxes)
for each source in whole dollars (no cents) 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.
How often?
Earnings from Work

Name of Adult Household Members (First and Last)

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 All Adult
Household Members
section.
Total Household Members
(Children and Adults)

STEP 4

Weekly

Weekly

How often?

Public Assistance/
Child Support/Alimony

Bi-Weekly 2x Month Monthly

Weekly

Bi-Weekly

Pensions/Retirement/
All Other Income

2x Month Monthly

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

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

X X

X

X

How often?
Weekly

Bi-Weekly 2x Month

Check if no SSN

X

Contact information and adult signature. Mail Completed Form To: INSERT YOUR SCHOOL/DISTRICT MAILING ADDRESS HERE

“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.”

Street Address (if available)

Printed name of adult signing the form

Apt #

City

Signature of adult

State

Zip

Daytime Phone and Email (optional)

Today’s date

Monthly

INSTRUCTIONS

Sources of Income

Sources of Income for Adults

Sources of Income for Children
Sources of Child Income

Earnings from Work

Example(s)

- Earnings from work

- A child has a regular full or part-time job
where they earn a salary or wages

- Social Security
- Disability Payments
- Survivor’s 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 person outside the household

- A friend or extended family member
regularly gives a child spending money

-Income from any other source

- A child receives regular income from a
private pension fund, annuity, or trust

OPTIONAL

- Salary, wages, cash
bonuses
- Net income from selfemployment (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

Public Assistance /
Alimony / Child Support
- Unemployment benefits
- Worker’s compensation
- Supplemental Security

Income (SSI)

- Cash assistance from

State or local
government
- Alimony payments
- Child support payments
- Veteran’s benefits
- Strike benefits

Pensions / Retirement /
All Other Income
- Social Security

(including railroad
retirement and black lung
benefits)
- Private pensions or
disability benefits
- Regular income from
trusts or estates
- Annuities
- Investment income
- Earned interest
- Rental income
- Regular cash payments
from outside household

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
Asian
American Indian or Alaskan Native

Black or African American

White

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.

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.

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:

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,
disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or
funded by USDA.

Do not fill out

Native Hawaiian or Other Pacific Islander

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.

For School Use Only

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24 Monthly x 12
Total Income

Eligibility:

How often?

Weekly

Bi-Weekly

2x Month

Monthly

Household Size

Free

Reduced

Denied

Categorical Eligibility
Determining Official’s Signature

Date

Confirming Official’s Signature

Date

Verifying Official’s Signature

Date