State Agencies and LEAs/SFAs - SLT IC

Attachment N: Prototype Agreement for Disclosure of
Free and Reduced Price Information

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

This information is being collected by 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 30 minutes per response. The burden consists of the time it takes for School Food
Authorities and Special Milk Program operators to read the manual and to have a written
agreement with an agency to disclose children's free and reduced price meals and/or free milk
eligibility information. 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, 5th
Floor, Alexandria, VA 22314, ATTN: PRA (0584-0026). Do not return the completed form to this
address.

I. Purpose and Scope
[Insert Name of Determining Agency] and [Insert Name of Receiving Agency] acknowledge
and agree that children's free and reduced price meal and free milk eligibility information
obtained under provisions of the Richard B. Russell National School Lunch Act (42 U.S.C. 1751
et seq.) (NSLA) or Child Nutrition Act of 1966 (42 U.S.C. 1771 et seq.) (CNA) and the
regulations implementing these Acts is confidential information. This Agreement is intended to
ensure that any information disclosed by the (insert name of determining agency) to the (insert
name of receiving agency) about children eligible for free and reduced price meals or free milk
will be used only for purposes specified in this Agreement and that the (insert name of
determining agency) and (insert name of receiving agency) recognize that there are penalties
for unauthorized disclosures of this eligibility information.
II. Authority
Section 9(b)(6)(A) of the NSLA (42 U.S.C. 1758(b)(6)(A)) authorizes the limited disclosure of
children's free and reduced price meal or free milk eligibility information to specific programs
or individuals, without prior parent/guardian consent. Except that, the parent/guardian must
be provided the opportunity to decline to share eligibility information prior to the disclosure
for identifying children eligible for benefits under or enrolling children in the State Medicaid
Program and the Children’s Health Insurance Program (CHIP). Additionally, the statute
specifies that for any disclosures not authorized by the statute, the consent of children's
parents/guardians must be obtained prior to the disclosure.

Program

CHECK ALL THAT APPLY
Information Authorized

Medicaid or the State Children’s Health Insurance
Program (CHIP), administered by a State or local agency
authorized under titles XIX or XXI of the Social Security Act.

All eligibility information
unless parents elect not to
have information disclosed.

Specify Program:
State health program other than Medicaid/CHIP, administered
by a State agency or local agency.

Eligibility status only;
Prior consent not required.

Specify Program:
Federal health program other than Medicaid/CHIP
Specify Program:
Local health program

No eligibility information
unless prior parental or
guardian consent is obtained.

Specify Program:

No eligibility information
unless prior parental or
guardian consent is obtained.

Child Nutrition Program under the National School
Lunch Act or Child Nutrition Act

All eligibility information;
consent not required.

Specify Program:
Federal/State or local means tested nutrition program with
eligibility standards comparable to the National School Lunch
Program

Eligibility status only;
consent not required.

Specify Program:
Federal education program
Specify Program:

Eligibility status only;
consent not required.

III. Responsibilities
[Insert Name of Determining Agency] will:
When required, secure the consent of parents/guardians prior to any disclosure not authorized by
the National School Lunch Act or any regulations under that Act, unless prior consent is secured
by the receiving agency and made available to the determining agency;
For State Medicaid and CHIP, notify parents/guardians of potential disclosures and provide
opportunity for parents/guardians to elect not to have information disclosed;

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Disclose eligibility information only to persons directly connected to the administration or
enforcement of programs authorized access under the National School Lunch Act or regulations
under the Act or to programs or services for which parents/guardians gave consent.
[Insert Name of Receiving Agency] will:
Ensure that only persons who are directly connected with the administration or enforcement of
the (insert name of the Program) and whose job responsibilities require use of the eligibility
information will have access to children's eligibility information:
Specify by name(s) or title(s) __________________________________________________
Use children's free and reduced price eligibility information for the following specific
purpose(s):
____________________________________________________________________________
____________________________________________________________________________
Inform all persons that have access to children's free and reduced price meal eligibility
information that the information is confidential, that children's eligibility information must only
be used for the purposes specified above, and the penalties for unauthorized disclosures.
Protect the confidentiality of children's free and reduced price meal or free milk eligibility
information as follows:
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
Specifically describe how the information will be protected from unauthorized uses and further
disclosures.
____________________________________________________________________________
____________________________________________________________________________
Description of Procedures to Transfer Meal Eligibility Information (may be completed by either
the determining agency or receiving agency)
____________________________________________________________________________
____________________________________________________________________________

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Describe the procedures for transferring students' meal eligibility information from the
determining agency to the requesting agency/program so as to limit the number of individuals
who have access to the information.
(Describe)
____________________________________________________________________________
____________________________________________________________________________
IV. Effective Dates
This agreement shall be effective from ______________________ to

.

V. Penalties
Any person who publishes, divulges, discloses, or makes known in any manner, or to any extent
not authorized by Federal law (Section 9(b)(6)(C) of the National School Lunch Act;
42 U.S.C. 1758(b)(6)(C)) or a regulation, any information about a child's eligibility for free and
reduced price meals or free milk, shall be fined not more than a $1,000 or imprisonment of not
more than 1 year or both.
VI. Signatures
The parties acknowledge that children's free and reduced price meal and free milk eligibility
information may be used only for the specific purposes stated above, and that unauthorized use
of free and reduced price meal and free milk information or further disclosure to other persons or
programs is prohibited and a violation of Federal law, which may result in civil and criminal
penalties.
Requesting Agency/Program Administrator:
Name: ___________________

Signature: ___________________

Title: ____________________

Date: _______________________

Phone: ___________________
Determining Agency Administrator:
Name: ___________________

Signature: ___________________

Title: ____________________

Date: _______________________

Phone: ___________________

*Any attachments will become part of this agreement.

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