Household - 7 CFR 245

Attachment J40. Prototype Household Application for Free and Reduced Price School Meals Somali
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

Codsiga Reerka ee Namuunadda ah looguna talagalay Cuntada Dugsi ee Bilaashka ah iyo Kuwa Qimahooda La Dhimay ee 2016-2017
U buuxi hal codsi reerkiiba. Fadlan isticmaal qalin (ma aha qalin rasaas).

TALLAABO 1

Liis garee DHAMMAAN Xubnaha Reerka ka tirsan ee ah dhallaanka, carruurta, iyo ardayda ilaa iyo heerka fasallada 12 dhigtaa ay ku jiraan (haddii meelo dheeraad ah loogu baahdo magaacda, ku soo lifaaq xaashi kale)
Xarafka Magac
Dhexaadka Magaca Dambe ee Ilmaha

Magaca Hore ee Ilmaha

Heer
Fasal

Carruurta ku jirta Qorshaha
daryeelka korriinka iyo carruurta
qanciya qeexidda ah Guri la'aanta,
Muhaajirka ama Baxsigaayaa u
mutaysan cuntada bilaashka ah.
Akhriso Sida loo codsado Cuntada
Dugsiga Bilaashka Ah Iyo Kuwa
Qiimahooda La Dhimay si aad
macluumaad dheeraad ah u hesho.

TALLAABO 2

Miyay midkoodna Xubnaha Reerku (oo aad adigu ku jirto) hadda ka qayb qaataan mid ama in ka badan barnaamijyada gargaarka soo socda: SNAP, TANF, ama FDPIR?
Hadday HAA tahay > Ku qor kees lambar halkan ka dibna u gudub TALLAABO 4
(Ha buuxin TALLAABADA 3)

Haddii ay MAYA tahay > U Gudub TALLAABO 3.

TALLAABO 3

Kees Lambar:
Kaliya ku qor hal kees lambar meeshan bannaan.

Ka Warbixi Dakhliga DHAMMAAN Xubnaha Reerka (Ka bood tallaabadan haddii aad kaga jawaabtay "Haa" TaLLAABO 2)
Intee jeer?

A. Dakhliga ilmaha

Dakhliga Ilmaha

Mararka qaarkood ayay carruurta reerka ka tirsani kasbadaan ama helaan dakhli. Fadlan ku dar WADARTA dakhli ay heleen
dhammaan Xubnaha Reerka ee ku qoran TAALLABO 1 halkan.
Adigu ma hubtid miyaa
dakhliga aad ku qorayso
halkan?
Rog bogga oo daalaco
jaartiga cinwaankiisu yahay
yahay "Ilaha Dakhliga" si
aad u hesho macluumaad
dheeraad ah.

Toddobaad Laba-JeerKasta
Toddobaadkii

2x Bishii

Bishii Kasta

$

B. Dhammaan Xubnaha Reerka ee Qaangaarka ah (oo aad adigu ku jirto)

Liis garee dhammaan Xubnaha Reerka aan ku qornayn TALLAABO 1 (adiguna aad ku jirto) xataa haddii ayna helin dakhli. Xubinta Reerka ee ku qoran meesha midkood kasta, haddii ay helaan dakhli, uga warbixi
dakhligooda guud (kahor canshuurta ) ilo kasta doollar buuxa ahaan kaliya (ha raacin sanaatiimta). Haddii aanay ka helin dakhli ilo kasta , ku qor ‘0’. Haddii aad geliso '0' ama aad ka tagto dulqor kasta bannaani, waxaad
caddaynaysaa (wacd ku qaadaysaa) inayna jirin dakhli laga warbixiyo.

Jaartiga "Ilaha Dakhliga
Qaangaarayaasha" ayaa kaa
caawin doonta qaybta
"Dhammaan Xubnaha
Reerka ee Qaangaarka ah".

Wadarta Xubnaha Reerka
(Carruurta iyo Qaangaarayaasha)

Gargaarka Dowladda/Taageerada
Ilmaha/Taageerada Afada Ama
Toddobaad
Seyga

Intee jeer?

Magaca Xubnaha Reerka ee Qaangaarka ah (Hore iyo
Dambe)

"Ilaha Dakhliga loogu
talagalay Carruurta" ayaa
kaa caawin doonta qaybta
Dakhliga Ilmaha.

TALLAABO 4

Ilmo Ku HGuri la'aan,
Qorshe Muhaajir,
Korriin ku jira Baxsi

Arday?
Haa
Maya
Calaamadee dhammaantood kuwa khuseeya

Qeexidda Xubinta Reerka: "Qof
kasta oo adiga kula nool oo kula
wadaaga dakhliga iyo kharashyada,
xataa haddii aydaan waxba isku
ahayn. "

Dakhliga laga Kasbado Shaqada Toddobaad
Kasta

Laba-JeerToddobaadkii

2x Bishii

Bishii Kasta

Kasta

Benshinka/Hawl Ka
Fariisiga/Dhammaan
Dakhliga Kale

Intee jeer?
Laba-JeerToddobaadkii

2x Bishii

Bishii Kasta

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Afarta tiro ee ugu dambeeya Lambarka Sooshal
Sekuuritiga (SSN) ee Qofka Hore ee Kasbada
Mushqaayadda ama Xubinta Qaangaarka ah ee Kale

X

X

X

X

X

Intee jeer?
Toddobaad Laba-JeerKasta
Toddobaadkii

2x Bishii

Bishii Kasta

Sax ku samee haddii aydaan lahayn SSN

Macluumaadka kula xiriirka iyo saxeexa qaangaaraha

Waxaan caddaynayaa (wacad ku qaadayaa) in dhammaan macluumaadka ku qoran codsigani yihiin kuwa run oo lagana warbixiyay dhammaan dakhliga. Waxaan fahamsanahay in macluumaadkan loo bixiyay arrimo la xiriira bixin dheef Federaal, oo ay mas'uuliyiinta dugsigu xaqiijin (soo baari)
karaan macluumaadka. Waan ogahay haddii aan anigu ula kaca u bixiyo macluumaad been ah, inay carruurtaydu loo waayi karaan dheefta cuntada, oo anigana dembi la igu soo oogi doono hoostooda sharciyada gobolka iyo Federaalka.”

Cinwaanka Jidka (haddii u jiro)

# Abaarman

Magaca qaangaaraha saxeexaya foomka oo far waawayn ku qoran

Magaalo

Saxeexa qaangaaraha

Gobol

Sib Koodhka

Telefoon lagaa heli karto maalinta iyo iimayl (waa ikhtiyaari)

Taariikhda maanta

TILMAAMAHA

Ilaha Dakhliga

Isha Dakhliga Qaangaarayaasha

Isha Dakhliga Carruurta

Dakhliga laga Kasbado Shaqada

Benshinka / Hawl Ka Fariisiga /
Dhammaan Dakhliga Kale

- Ilmaha ayaa haysta shaqo joogto ah oo buuxda
ama wakhti dhiman ah oo kasbada mushahar ama
mushqaayad
- Ilmaha ayaa indho-beel ama naafo ah oo qaataa
dheefaha Soshal Sekuritiga
-Waalid ayaa naafo, shaqo ka fariisi ah, ama
dhintay, oo ilmaha ayaa hela dheefaha sooshal
sekuuritiga,

Gargaarka Dowladda / Taageerada
Afada Ama Seyga / Taageerada Ilmaha

- Mushahar, mushqaayad, gunno
lacag kaash ah
- Dakhliga saafiga ee laga helo
iskaa-u-shaqaysiga (beer ama
meherad)

-Dakhli laga helo qof reerka ka baxsan

- Saaxiib ama xubin ehelka qoyska ka mid
ah ayaa si joogto ah u siiyaa ilmaha lacag
kharashayn

-Dakhli laga helo il kasta oo kale

- Ilmo ayaa ka hela dakhli joogto ah ka
fuundo hawlgab gaar ah, lacag u ururtay,
ama ammano ah

- Mushaharka asaasiga ah iyo
gunnooyinka lacagta kaashka ah
(Ha KU darin lacagta xarbiga,
FSSA ama gunnooyinka
guriyaynta gaar ahaansan)
- Gunnooyinka guriyaynta
saldhigga-ka-baxsan, cuntada iyo
dharka

- Dheefaha shaqo la'aanta
- Magdhowga shaqaalaha
- Dakhliga Kaabitaanka Sooshal
Sekuuritiga (SSI)
- Gargaarka kaashka ah ee laga
helo gobolka ama dawladda
deegaanka
- Biximaha la siiyo afo ama sey la
kala tagay
- Biximaha taageerada ilmaha
- Dheefaha horay uga tirsanaan
ciidamo
- Dheefaha shaqo joojinta

- Sooshal Sekuritiga(oo ay ku
jiraan hawlgabka xadiidka iyo
dheefaha sambabbada
madoobaada)
- Hawlgabka gaarka ah ama
dheefaha naafada
- Dakhliga joogtada ah ee laga
helo aammnaysiga ama
milkiyadaha
- Lacagaha urursmay
- Dakhli maaligashi
- Dulsaarka la kasbaday
- Dakhli kiro
- Biximo lacag kaasha ah oo si
joogto ah looga helo in ka
baxsan reerka

Tusaale(ooyin)

Ilaha Dakhliga Ilmaha
- Dakhliyada laga kasbado shaqada
- Sooshaal Sekuuritiga
- Biximaha Naafanimada
- Dheefaha Dhaxalka

IKHTIYAARI LAGU BUUXINAYO

Haddii aad ku jirto Ciidamada
Maraykanka:

Aqoonsiga Isireed Iyo Qowmiyeed ee Carruurta

Waxa la nooga baahan yahay inaan ku weyddiinoo macluumaadka ku saabsan isirka iyo qowmiyadda carruurtaada. Macluumaadkani waa muhiim oo waxay waxtar uga yeelanaysaa sidii loo hubin inaan si
buuxda ugu adeegeyno jaalidyaddeena. Ka jawaabidda qaybtan ayaa ikhtiyaar ah oo ma saamayn doonto u mutaysnaanta carruurta ee cuntada bilaashka ah ama qiimaha laga dhimay.

Qowmiyadda (mid calaamee):
Hisbaanik ama Laatiino
Aan Ahayn Hisbaanik ama Laatino
Isirka (calaamadee mid ama in ka badan):
Hindi Maryakan ama ama Dhalad Alaaska
Aasiyaan
Jasiiradaha Kale ee Basafiigga
Caddaan

Madow ama Afrikaan Ameerikan

Dhalad Hawaaii ama

adka naafada ah ee u baahan hab kale oo wada xiriir marka loogu talagalo macluumaadka barnaamijka (tusaale
ahaan Braille, daabaca farta waawayn, cajaladda maqalka, Luqadda Calaamadaynta Maraykanka, iwm.), waa inay
la xiriiraan Hay'adda (Gobolka ama Deegaanka) ay ka codsadeen dheefaha. Shaqsiyaadka maqal la'aanta ah ama
maqalka ku adag yahay ama naafanimo hadal leh ayaa kula xiriiri kara USDA Adeegga tebinta Federaalka (Federal
Relay Service) lambarkan (800) 877-8339. Intaa waxa u dheer, macluumaad barnaamijka oo dhici karta in lagu
bixiyo luqadaha aan Ingiriisiga ahayn.
Inaad xereyso cabasho kala qoqob barnaamijka oo takoor, buuxi Foomka Cabashada USDA ee kala Qoqobka
Barnaamijka, (AD-3027) ee laga helo onlayn bartan http://www.ascr.usda.gov/complaint_filing_cust.html, iyo xafiis
kasta oo USDA, ama warqad u qor adiga oo ku hagaajiya USDA oo ku bixi warqadda macluumaad kasta oo lagu
weyddiistay foomka. Inaad weyddiisato nuqul foomka cabashada ah, wac (866) 632-9992. U gudbi foomka la buuxiyay
ama warqadda USDA:
boosta:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410
faakis:
(202) 690-7442; ama

Xeerka Qadada Dugsiga Qaranka ee Richard B. Russell ayaa u baahan macluumaadka ku qoran codsigan. Qasab
kuguma aha inaad bixiso macluumaadka, laakiin haddii aadan bixin, uma oggolaan karno ilmahaaga cuntada
bilaashka ah ama qiimaha la dhimay. Waa inaad soo raacisaa afarta tiro ee ugu dambaysa lambarka sooshal
sekuritiga xubinta reerka ee qaangaaraha ah ee saxeexa codsiga. Afarta tiro ee ugu dambaysa lambarka sooshal
sekuritiga looma baahna markaad ugu codsanayso magaca qorshaha korriinka kuugu hoos jira ama aad qorto
Barnaamijka Gargaarka Nafaqada Kaamilinta ah (SNAP), kees lambarka Barnaamijka Gargaarka Ku Meelgaarka
ah ee Qoysaska Baahan (TANF) ama Barnaamijka Cunto Qaybinta Deegaannada Hindida (FDPIR) ama aqoonsasho
FDPIR oo kale looguna talagalay ilmahaaga ama markaad tilmaamto xubinta reerka ee qaangaarka ahi aanu lahayn
lambar sooshal sekuriti. Waxaan u isticmaali doonaa macluumaadkaaga in la go'amiyo haddii u ilmahaagu uu u
mutaysan yahay cuntada bilaashka ah ama qiimaha la dhimay, iyo maamulka iyo fulinta barnaamijyada qadada
iyo quracda. Waxa DHICI karta inaan la wadaagno macluumaadkaaga u mutaysiga barnaamijyada waxbarashada,
caafimaadka, iyo nafaqada si ay qiimeeyaan, raasamaaleeyaan ama u go'aamiyaan dheefaha loogu talagalay dib u
eegga barnaamijka, saraakiisha fulinta sharciga si ay iyagana uga caawiso inay eegaan in lagu xadgudbay xeerarka
barnaamijka.
Marka la raaco sharciga xuquuqda madaniga ah ee Federaalka iyo Waaxda Beeraha ee Dawladda Maraykanka (USDA)
iyo xeerarka xuquuqda iyo ujeeddooyinkeed madaniga ah, ayaa USDA, Hay'adaheeda, xafiisyadeeda, iyo shaqaalaheeda,
iyo hay'adaha ka qaybqaadanaya ama maamulaya barnaamijada USDA ayaa laga ka mamnuucan inay ku kala qoqobaan
dadka iyada oo salka ku haysa jinsiyad, midab, asal qowmiyadeed, jinsi, naafanimo, da'da, rogaal celin ama ka aarsasho
awgeed hawl hore oo xuquuq madani barnaamij ama hawl kasta oo ay raasamaalayso USDA.

iimayl:

[email protected].

Hay’addan ayaa ah bixiye furasad siman.

Ha buuxin

Loogu Talagalay Kaliya Isticmaalka Dugsiga

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