Household - 7 CFR 245

Attachment J20: Prototype Household Application for Free and Reduced Price School Meals Igbo
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.

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

2016-2017 Ọkọlọtọ Akwụkwọ Anamachọihe Ezinụlọ maka Nri Ụlọ Akwụkwọ Bụ N'efu yana Nke Belatara Ego
Dejuputa otu akwụkwọ anamachọihe kwa ezinụlọ. Biko jiri mkpịsị ọdee (ọbụghị pensịl).

Deputa Ndị Otu Ezinụlọ NIILE ndị bụ ụmụ ntakịrị, ụmụaka, yana ụmụ akwụkwọ ruru ma gụnye akara 12 (ọ bụrụ na achọkwuru oghere maka aha ndị ọzọ, gbakwunye mpempe akwụkwọ ọzọ)

Nkọwa nke Onye Otu Ezinụlọ:
"Onye ọ bụla binyere gị ma na
ekekọrịta na ụgwọ ọnwa na ego
mmefu, ọbụlagodi na ọ bụghị
nwanne gị."

Aha Izizi nke Nwata ahụ

MI

Aha Nna nke Nwata ahụ

Ụmụaka nọ na nlekọta
Nkuchi yana ụmụaka zutere
nkọwa nke Onye Enweghị
Ebe Obibi, Onye Mbịambịa
ma ọ bụ Onye Gbapụrụ N'ụlọ
tozuru maka nri bụ n'efu. Gụọ
Otu esi Etinye Akwụkwọ
maka Nri Ụlọ Akwụkwọ Bụ
N'efu yana Nke Belatara Ego
maka ozi ndị ọzọ.

USORO 2

Onye Enweghị Ebe
Obibi, Onye
Nwata mbịambịa,
Onye
Ekuchiri Gbapụrụ n'ụlọ

Nwa akwụkwọ?
Ee
Mba

Akara

Kapụta ihe niile emetụtara

USORO 1

Enwere Ndị Otu Ezinụlọ ọ bụla (gụnyere gị) na esonye ugbu a n'otu mmemme enyemaka ndị a: SNAP, TANF, ma ọ bụ FDPIR?
Ọ bụrụ MBA > Gaa na USORO 3.

Nọmba nrịbama:

Ọ bụrụ Ee > Dee nọmba nrịbama ebe a wee gaa na USORO 4 (Edejuputana USORO 3)

Dee naanị otu nọmba nrịbama n'oghere a.

USORO 3

Kpesa Ụgwọ ọnwa maka Ndị Otu Ezinụlọ NIILE (Mafere usoro a ma ọ bụrụ na ị zara 'Ee' na USORO 2)
Ugboro ole?

A. Ụgwọ Ọnwa nke Nwata

Ụgwọ Ọnwa nke Nwata

Oge ụfọdụ ụmụaka nọ n'ezinụlọ na erite ma ọ bụ nweta ụgwọ ọnwa. Biko gụnye MGBAKỌTA ụgwọ ọnwa nke Ndị Otu Ezinụlọ niile
nwetara edepụtara na USORO 1 ebe a.

Wefee ibe ahụ wee nyochaa
chaatị akpọrọ "Ụzọ Esi Enweta
Ego" maka ozi ndị ọzọ.

Kwa ọnwa
abụọ Kwa ọnwa

Depụta Ndị Otu Ezinụlọ niile edepụtaghị na USORO 1 (gụnyere onwe gị) ọbụlagodi na ha anaghị enweta ụgwọ ọnwa. Maka Ndị Otu Ezinụlọ ọ bụla edepụtara, ọ bụrụ na ha na enweta ụgwọ ọnwa, kpesa nchịkọta ụgwọ ọnwa
(tupu ụtụ isi) maka ụzọ ọ bụla esi enweta ego na dollars zuru oke (achọghị cents). Ọ bụrụ na ị naghị enweta ụgwọ ọnwa n'ụzọ ọ bụla, dee '0'. Ọ bụrụ na i tinye '0' ma ọ bụ hapụ ogige ọ bụla oghe, ị na ekwupute (ekwe nkwa)
na enweghị ụgwọ ọnwa ọ bụla ịkpesa.
Enyemaka Ọhaneze/ Nkwado
Nwata/Ụgwọ A Na Akwụ Ndị
Gbara Alụkwaghị M

Ugboro ole?
Aha nke Ndị Otu Ezinụlọ Bụ Okenye (Izizi na Aha Nna)

Chaatị "Ụzọ Ụmụaka Si
Enweta Ego" ga-enyere
gị aka na ngalaga Ụgwọ
ọnwa nke Nwata ahụ.
Chaatị "Ụzọ Ndị Okenye Si
Enweta Ego" ga-enyere gị
aka na ngalaba Ndị Otu
Ezinụlọ Niile Bụ Okenye.

Nrite sitere na Ọrụ

Kwa izu

Kwa izu
abụọ

Kwa ọnwa
abụọ Kwa ọnwa

Ego Ezumike Nka/Ịla
Ezumike Nka/Ụzọ Ndị Ọzọ
Niile Esi Enweta

Ugboro ole?
Kwa izu

Kwa izu
abụọ

Kwa ọnwa
abụọ Kwa ọnwa

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Mkpụrụọnụọgụ Anọ ikpeazụ nke Social Security
Number (SSN) nke Onye Kachasị Erite Ụgwọ ma
ọ bụ Onye Otu Ezinụlọ Bụ Okenye

Mgbakọta Ndị Otu Ezinụlọ
(Ụmụaka na Ndị Okenye)

USORO 4

Kwa izu
abụọ

$

B. Ndị Otu Ezinụlọ Niile Bụ Okenye (gụnyere onwe gị)
O doghi gị anya ụgwọ ọnwa
ị ga-agụnye ebe a?

Kwa izu

X

X

X

X

X

Ugboro ole?
Kwa izu

Kwa izu
abụọ

Kwa ọnwa
abụọ Kwa ọnwa

Tinye nrịbama ọ bụrụ na enweghị SSN

Ozi mkpọtụrụ yana akara aha nke okenye

"Ekwuputere m na (ekwe nkwa) na ozi niile dị n'akwụkwọ anamachọihe a ziri ezi, na ekpesara ụgwọ ọnwa niile. Aghọtara m na enyere ozi a na njikọ nke nnata nke ego Etiti Obodo, na ndị ọrụ ụlọ akwụkwọ ahụ nwere ike inyocha (lelee) ozi ahụ. Amara m na m nye ozi na ezighi ezi, enwere ike ịnapụ ụmụaka
m elele nri, enwekwara ike ịma m ikpe n'okpuru iwu Steeti na Etiti Obodo emetụtara."

Adreesị Striiti (ọ bụrụ na ọ dị)

Aha nke okenye na ebinye aka n'akwụkwọ ahụ ebipụtara

Akara ụlọ

Obodo

Akara aha nke okenye

Steeti

Zip

Ekwentị Ụbọchị na Email (nhọrọ)

Ụbọchị taa

NTUZIAKA

Ụzọ Esi Enweta Ego

Ụzọ Ndị Okenye Si Enweta Ego

Ụzọ Ụmụaka Si Enweta Ego
Nrite sitere na Ọrụ

Ịmaatụ

Ụzọ Nwata Si Enweta Ego

- Nrite sitere na Ọrụ

- Nwata nwere ọrụ ebe ha na erite ụgwọ ọnwa

- Nchedo Ọhaneze
- Akwụmụgwọ maka Nkwarụ
- Elele nke Ndị Dịrị Ndụ

- Nwata kpuru isi ma ọ bụ nwere nkwarụ ma na
enweta elele Nchedo Ọhaneze
- Nne ma ọ bụ nna nwere nkwarụ, alaala ezumike
nka, ma ọ bụ nwụrụ anwụ, ma nwata ahụ na
enweta elele nchedo ọhaneze

- Ego si n'aka mmadụ na esoghi n'ezinụlọ ahụ

- Enyi ma ọ bụ onye onye ikwunibe na enye
nwata ego mmefu kwa oge

- Ego si n'ụzọ ọzọ ọ bụla

- Nwata na enweta ego site na ego ezumike
nka nkeonwe, ụgwọ a na akwụ kwa afọ, ma
ọ bụ ego nchekwa

NHỌRỌ

Enyemaka Ọhaneze / Ụgwọ A Na Akwụ Ndị
Gbara Alụkwaghị M / Nkwado Nwata

- Elele ndị anaghị arụ ọrụ
- Ego nkasi obi nke onye ọrụ
- Mgbakwunye Ụgwọ Ọnwa
Nchekwa (SSI)
- Enyemaka ego si n'aka gọọmentị
Ọ bụrụ na i so na Ndị Agha U.S.:
Steeti ma ọ bụ mpaghara
- Akwụmụgwọ a na akwụ ndị
- Ọkọlọtọ akwụmụgwọ na elele
ego (agụnyena ụgwọ ọgụ, FSSA gbara alụkwaghị m
ma ọ bụ nchọnchọ ego maka ụlọ - Akwụmụgwọ nkwado nwata
- Elele ndị agha ochie
obibi erere)
- Elele abụba ọrụ
- Nchọnchọ ego maka ụlọ obibi
dịpụrụ adịpụ, nri na uwe
- Ụgwọ, elele ego
- Mgbakọ ụgwọ ọnwa si ọrụ nke
ya (ubi ma ọ bụ azụmahịa)

Ego Ezumike Nka / Ịla Ezumike Nka / Ụzọ
Ndị Ọzọ Niile Esi Enweta Ego

- Nchedo Ọhaneze (gụnyere elele
ịla ezumike nka nke ndị okporo
ụgbọ oloko yana ngụ ojii)
- Elele Ego Ezumike Nka
Nkeonwe ma ọ bụ nkwarụ
- Ego ndị si na ego nchekwa
ma ọ bụ ụlọ
- Ụgwọ a na akwụ kwa afọ
- Ego enwetara n'azụmahịa
etinyere ego
- Ego ọmụrụnwa enwetara
- Ego enwetara na mgbazinye
- Akwụmụgwọ ego ndị si na
ezinụlọ dị na mpụga

Njirimara Agbụrụ na Obodo nke Ụmụakat

Achọrọ ka anyị jụọ ozi maka agbụrụ na obodo ụmụaka gị. Ozi a dị anyị mkpa ma nyere aka ịhụ na anyị na agbara ogbe anyị mbo n'uju. Ịzaghachi ngalaba bụ ihe nhọrọ, ọ naghị emetụta
ntozu ụmụaka gị maka nri bụ n'efu ma ọ bụ nke belatara ego.
Agbụrụ (kapụta otu):

Onye Spain ma ọ bụ Latino

Agbụrụ (kapụta otu ma ọ bụ karia):

Abụghị Onye Spain ma ọ bụ Latino

Onye Amaala India na Amerika ma ọ bụ Alaska

Onye Asia

Onye Isi Ojii ma ọ bụ Africa na Amerika

Onye ocha

Ndị mmadụ nwere nkwarụ ndị chọrọ ụzọ nkwukọrịta ọzọ maka ozi mmemme (dịka Braille, nnukwu mbipụta, teepu
ọdịyo, Asụsụ Akara nke America, wdg.), kwesịrị ịkpọtụrụ Ndị Nnọchite (Steeti ma ọ bụ mpaghara) ebe ha tinyere
akwụkwọ maka elele. Ndị mmadụ dara ogbi, nti ike ma ọ bụ nwere nkwarụ ekwumokwu nwere ike ịkpọtụrụ USDA site
na Federal Relay Service na (800) 877-8339. Ọzọkwa, enwere ike ịnye ozi mmemme n'asụsụ nke ọzọ na abụghị Bekee.

Atụmatụ Mba maka Nri Ehihie N'ụlọ Akwụkwọ nke Richard B. Russell chọrọ ozi dị n'akwụkwọ anamachọihe a.
Ị gaghị enyerịrị ozi ahụ, mana ọ bụrụ na ị nyeghị, anyị agaghị akwado nwata gị maka nri bụ n'efu ma ọ bụ nke belatara
ego. Ị ga-agụnyerịrị mkpụrụọnụọgụ anọ ikpeazụ nke nọmba nchedo ọhaneze nke onye otu ezinụlọ bụ okenye binyere
aka n'akwụkwọ anamachọihe ahụ. Achọghị mkpụrụọnụọgụ anọ ikpeazụ nke nọmba nchedo ọhaneze mgbe ị na etinye
akwụkwọ na nnọchite nke nwata ekuchiri ma ọ bụ na ị depụtara nọmba nrịbama Mmemme Enyemaka Mgbakwunye
Nri (SNAP), Mmemme Obere Enyemaka maka Ezinụlọ Ndị Nọ Na Mkpa (TANF) ma ọ bụ Mmemme Nkesa Nri na Nchedo
nke India (FDPIR) ma ọ bụ ihe nkọwapụta FDPIR ọzọ maka nwata gị ma ọ bụ mgbe i gosipụtara na onye otu ezinụlọ
bụ okenye na ebinye aka n'akwụkwọ anamachọihe ahụ enweghị nọmba nchekwa ọhaneze. Anyị ga-eji ozi gị iji kpebie
ma nwata gị etozuru maka nri bụ n'efu ma ọ bụ nke belatara ego, yana maka nchịkwa na mmanye nke mmemme nri
ehihie na nri ụtụtụ. Anyị NWERE IKE ịkekọrịta ozi ntozu gị n'etiti agụmakwụkwọ, ahuike, yana mmemme nri dị mma iji
nyere ha aka nyochaa, nye ego, ma ọ bụ kpebie elele maka mmemme ha, ndị nnyocha maka nyocha mmemme, yana
ndị ọrụ mmanye iwu iji nyere aha aka lenye anya n'ime ngabiga nke iwu mmemme.

Iji tinye akwụkwọ maka mkpesa mmemme nke ịkpa oke, dejuputa Akwụkwọ Mkpesa Ịkpa Oke na Mmemme USDA,
(AD-3027) ahụrụ n'ịntanetị na: http://www.ascr.usda.gov/complaint_filing_cust.html, yana n'ụlọ ọrụ USDA ọ bụla,
ma ọ bụ dee leta degara USDA ma weta leta nke ozi niile arịrịọ n'akwụkwọ ahụ. Iji rịọ nnomi nke akwụkwọ mkpesa
ahụ, kpọọ (866) 632-9992. Nyefee akwụkwọ ma ọ bụ leta gị edejuputara na USDA tupu:
ozi:

U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410

N'usoro nke iwu ikike mmadụ Etiti Obodo yana iwu na usoro ikike mmadụ nke U.S. Department of Agriculture (USDA),
USDA, amachiri Ndị Nnọchite ya, ụlọ ọrụ, yana ndị ọrụ, ewumewu na esonye na ma ọ bụ na eweta mmemme USDA
na ịkpa oke dabere na agbụrụ, anụ ahụ, mba ala, okike, nkwarụ, afọ, ma ọ bụ nkwụghachi ma ọ bụ ịbọ ọbọ maka
mmemme ikike mmadụ meburu na mmemme ọ bụla ma ọ bụ omume emere ma ọ bụ kwado site n'aka USDA.

Edejuputana

Onye Amaala Hawaii ma ọ bụ Ndị Agwa Etiti Ndị Ọzọ

faksị:

(202) 690-7442; or

email:

[email protected].

Ewumewu a bụ ndị na eweta ohere hakọrọ.

Naanị Maka Ojiji Ụlọ Akwụkwọ

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

Eligibility:

How often?

Total Income

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