Household - 7 CFR 245

Attachment K: Prototype Application Instructions
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 read this information and 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

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

HOW TO APPLY FOR FREE AND REDUCED PRICE SCHOOL MEALS

Please use these instructions to help you fill out the application for free or reduced price school meals. You only need to submit one application per household,
even if your children attend more than one school in [School District]. The application must be filled out completely to certify your children for free or reduced
price school meals. Please follow these instructions in order! Each step of the instructions is the same as the steps on your application. If at any time you are not
sure what to do next, please contact [School/school district contact here; phone and email preferred].
PLEASE USE A PEN (NOT A PENCIL) WHEN FILLING OUT THE APPLICATION AND DO YOUR BEST TO PRINT CLEARLY.

STEP 1: LIST ALL HOUSEHOLD MEMBERS WHO ARE INFANTS, CHILDREN, AND STUDENTS UP TO AND INCLUDING GRADE 12
Tell us how many infants, children, and school students live in your household. They do NOT have to be related to you to be a part of your household.
Who should I list here? When filling out this section, please include ALL members in your household who are:
 Children age 18 or under AND are supported with the household’s income;
 In your care under a foster arrangement, or qualify as homeless, migrant, or runaway youth;
 Students attending [school/school system here], regardless of age.
A) List each child’s name. Print each child’s
B) Is the child a student at [name
C) Do you have any foster children? If any children
D) Are any children homeless, migrant,
name. Use one line of the application for each
of school/school system here]?
listed are foster children, mark the “Foster Child”
or runaway? If you believe any child
child. When printing names, write one letter in Mark ‘Yes’ or ‘No’ under the
box next to the child’s name. If you are ONLY
listed in this section meets this
each box. Stop if you run out of space. If there
column titled “Student” to tell us
applying for foster children, after finishing STEP 1,
description, mark the “Homeless,
are more children present than lines on the
which children attend [name of
go to STEP 4.
Migrant, Runaway” box next to the
application, attach a second piece of paper
school/school district here]. If you Foster children who live with you may count as
child’s name and complete all steps of
with all required information for the additional marked ‘Yes,’ write the grade level members of your household and should be listed on the application.
children.
of the student in the ‘Grade’
your application. If you are applying for both foster
column to the right.
and non-foster children, go to step 3.

STEP 2: DO ANY HOUSEHOLD MEMBERS CURRENTLY PARTICIPATE IN SNAP, TANF, OR FDPIR?
If anyone in your household (including you) currently participates in one or more of the assistance programs listed below, your children are eligible for free school meals:
 The Supplemental Nutrition Assistance Program (SNAP) or [insert State SNAP here].
 Temporary Assistance for Needy Families (TANF) or [insert State TANF here].
 The Food Distribution Program on Indian Reservations (FDPIR).
A) If no one in your household participates in any of the above B) If anyone in your household participates in any of the above listed programs:
listed programs:
 Write a case number for SNAP, TANF, or FDPIR. You only need to provide one case number. If you participate
 Leave STEP 2 blank and go to STEP 3.
in one of these programs and do not know your case number, contact: [State/local agency contacts here].
 Go to STEP 4.

STEP 3: REPORT INCOME FOR ALL HOUSEHOLD MEMBERS
How do I report my income?


Use the charts titled “Sources of Income for Adults” and “Sources of Income for Children,” printed on the back side of the application form to determine if your household has
income to report.
 Report all amounts in GROSS INCOME ONLY. Report all income in whole dollars. Do not include cents.
o Gross income is the total income received before taxes.
o Many people think of income as the amount they “take home” and not the total, “gross” amount. Make sure that the income you report on this application has NOT been

STEP 3: REPORT INCOME FOR ALL HOUSEHOLD MEMBERS



reduced to pay for taxes, insurance premiums, or any other amounts taken from your pay.
Write a “0” in any fields where there is no income to report. Any income fields left empty or blank will also be counted as a zero. If you write ‘0’ or leave any fields blank, you are
certifying (promising) that there is no income to report. If local officials suspect that your household income was reported incorrectly, your application will be investigated.
Mark how often each type of income is received using the check boxes to the right of each field.

3.A. REPORT INCOME EARNED BY CHILDREN
A) Report all income earned or received by children. Report the combined gross income for ALL children listed in STEP 1 in your household in the box marked “Child Income.” Only
count foster children’s income if you are applying for them together with the rest of your household.
What is Child Income? Child income is money received from outside your household that is paid DIRECTLY to your children. Many households do not have any child income.

3.B REPORT INCOME EARNED BY ADULTS
Who should I list here?
 When filling out this section, please include ALL adult members in your household who are living with you and share income and expenses, even if they are not related and even
if they do not receive income of their own.
 Do NOT include:
o People who live with you but are not supported by your household’s income AND do not contribute income to your household.
o Infants, Children and students already listed in STEP 1.
B) List adult household members’
C) Report earnings from work. Report all income from work in the
D) Report income from public assistance/child
names. Print the name of each
“Earnings from Work” field on the application. This is usually the
support/alimony. Report all income that applies in the “Public
household member in the boxes marked
money received from working at jobs. If you are a self-employed
Assistance/Child Support/Alimony” field on the application. Do
“Names of Adult Household Members
business or farm owner, you will report your net income.
not report the cash value of any public assistance benefits NOT
(First and Last).” Do not list any
listed on the chart. If income is received from child support or
household members you listed in STEP 1. What if I am self-employed? Report income from that work as a net alimony, only report court-ordered payments. Informal but
If a child listed in STEP 1 has income,
regular payments should be reported as “other” income in the
amount. This is calculated by subtracting the total operating
follow the instructions in STEP 3, part A.
next part.
expenses of your business from its gross receipts or revenue.
E) Report income from
pensions/retirement/all other income.
Report all income that applies in the
“Pensions/Retirement/ All Other
Income” field on the application.

F) Report total household size. Enter the total number of household
members in the field “Total Household Members (Children and
Adults).” This number MUST be equal to the number of household
members listed in STEP 1 and STEP 3. If there are any members of
your household that you have not listed on the application, go back
and add them. It is very important to list all household members, as
the size of your household affects your eligibility for free and
reduced price meals.

G) Provide the last four digits of your Social Security Number.
An adult household member must enter the last four digits of
their Social Security Number in the space provided. You are
eligible to apply for benefits even if you do not have a Social
Security Number. If no adult household members have a Social
Security Number, leave this space blank and mark the box to the
right labeled “Check if no SSN.”

STEP 4: CONTACT INFORMATION AND ADULT SIGNATURE
All applications must be signed by an adult member of the household. By signing the application, that household member is promising that all information has been truthfully
and completely reported. Before completing this section, please also make sure you have read the privacy and civil rights statements on the back of the application.
A) Provide your contact information. Write your current
B) Print and sign your name and
C) Mail Completed
D) Share children’s racial and ethnic identities
address in the fields provided if this information is available. write today’s date. Print the name Form to: Insert
(optional). On the back of the application, we ask you
If you have no permanent address, this does not make your
of the adult signing the application School/District
to share information about your children’s race and
children ineligible for free or reduced price school meals.
and that person signs in the box
address here
ethnicity. This field is optional and does not affect your
Sharing a phone number, email address, or both is optional, “Signature of adult.”
children’s eligibility for free or reduced price school
but helps us reach you quickly if we need to contact you.
meals.