Attachment J1. Prototype Household Application for Free and Reduced Price School Meals English

Attachment J1: Prototype Household Application for Free and Reduced Price School
Meals (English)
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# 0584-0026 Expiration Date: X/XX/20XX

APPLY ONLINE:
RETURN TO (School/District Name):
ADDRESS:

Prototype Household Application for Free and Reduced Price School Meals
Complete one application per household. Please use a pen (not a pencil).

STEP 1

List ALL children, infants, and students up to and including grade 12. Attach another sheet of paper if you need space for more names.

List ALL children in the household. Do not forget to list infants, children attending other schools, children not in school, and children not applying for benefits. This includes children not related to you in your household.
Grade
Child’s First Name
MI Child’s Last Name
Foster Child Migrant Runaway Homeless
Check all that apply

If you checked
any of these
boxes, please
refer to the
Application
Instruction’s
Step 1: Part C &
Part D.

STEP 2
NO

Do any household members (including you) participate in: SNAP, TANF, or FDPIR?

Go to STEP 3.

YES

CASE NUMBER (NOT EBT NUMBER):

Write case number here and proceed to STEP 4.

Write only one case number in this space.

STEP 3

List ALL household members and income for each member (before taxes and deductions)

A. All Adult Household Members (Anyone who is living with you and shares income and expenses, even if not related, including you.)
List all Adult Household Members not listed in STEP 1 (including yourself ) even if they do not receive income. For each Household Member listed, if they receive income, report total gross income (before taxes and
deductions) 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.
Public Assistance,
Child Support,
Alimony

How often received?
Earnings from Work

Name of Adult Household Members (First and Last)

Weekly

Every
2 Weeks

Monthly

Annual

2x Month

Monthly

$

$

$

$

$

$

$

$

$

$

$

$

$

$

B. Child Income

Sometimes children in the household earn or receive income.
Include the TOTAL income (before taxes and deductions) received by ALL children listed in STEP 1 here.

Contact information and adult signature.

Weekly

Every
2 Weeks

$

Last Four
Four Numbers of Social
Social Secur
Securit
ityy Number of
Primar
imaryy Wage Earner
Earner or other Adult
Adult Household
Member (If
(If Applicable)
Applicable)

Total Household Members (Children and Adults)

STEP 4

2x Month

Pensions, Retirement,
Social Security, SSI,
VA Benefts, All Other

How often received?

Child Income

Check if no Social
Social
Secur
ecurit
ityy Number
How often received?
Weekly

Every
2 Weeks

2x Month

Monthly

How often received?
Weekly

Every
2 Weeks

2x Month

Monthly

Please see application’s back
for list of income sources.

Annual

$

RETURN COMPLETED FORM TO YOUR CHILD’S SCHOOL: Insert school 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 ofcials may verify
(confrm) the information. I am aware that if I purposely give false information, my children may lose meal benefts, and I may be prosecuted under applicable State and Federal laws.”

Signature of Adult

Print Name of Adult Signing the Form

Mailing Address (if available)

City

Return completed form to your child’s school.

State

Today’s Date

Zip

Phone (optional)

Email (optional)

SOURCES AND EXAMPLES OF INCOME

For additional information on income, please refer to the instructions that accompany this application.
Sources of Income

Earnings from Work
• Salary, wages, cash bonuses, tips, commissions
• Net income from self-employment
(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 of-base housing, food,
and clothing

OPTIONAL

Examples of Income for Children

Public Assistance/Alimony/
Child Support

Pensions/Retirement/
All other sources of income

•
•
•
•

• Social Security/Disability (including railroad
retirement and black lung benefts)
• Private Pensions or disability benefts
• Income from trusts or estates
• Annuities
• Investment income
• Earned interest
• Rental income
• Regular cash payments from
outside household

•
•
•
•

Unemployment benefts
Workers' compensation
Supplemental Security Income (SSI)
Cash assistance from State or local
government
Alimony payments
Child support payments
Veterans benefts
Strike benefts

• A child has a regular full or part-time job where they earn a salary or wages
• A child is blind or disabled and receives Social Security benefts
• A parent is disabled, retired, or deceased, and their child receives Social Security benefts
• A friend or extended family member regularly gives a child spending money

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

Children’s ethnic and racial identities. This information is kept confdential and may be protected by the Privacy Act of 1974.

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 afect your children’s eligibility for free or reduced price meals.
Ethnicity (check one):

Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin, regardless of race)

Race (check one or more):

American Indian or Alaska Native

Asian

Black or African American

Not Hispanic or Latino

Native Hawaiian or Other Pacifc Islander

White

Return this completed form to your child’s school. *Do not mail, fax, or email completed applications to the U.S. Department of Agriculture Ofce of the Assistant Secretary for Civil Rights.

DO NOT FILL OUT

For school use only.

Annual Income Conversion: Weekly × 52, Every 2 Weeks × 26, Twice a Month × 24, Monthly × 12. Do not annualize income to determine eligibility unless more than one income frequency is listed.
How often?

Total Income

Determining Ofcial’s Signature

Weekly

Every
2 Weeks

2x Month

Date

Monthly

Annual

Free

Categorical Eligibility

Confrming Ofcial’s Signature

Use of Information Statement
The Richard B. Russell National School Lunch Act requires that we use information
from this application to see who qualifes for free or reduced price meals. We can only
approve complete forms. We may share your eligibility information with education, health,
and nutrition programs to help them deliver program benefts to your household. Inspectors
and law enforcement may also use your information to make sure that program rules are met.
Please be sure to provide the last four numbers of the Social Security number of the adult
household member who signs the application. If the adult does not have one, ‘Check if no
Social Security Number.’ Applications for a foster child do not need to list a Social Security
number. Applications for children in households receiving Supplemental Nutrition Assistance
Program (SNAP) or Temporary Assistance for Needy Families (TANF) or Food Distribution
Program on Indian Reservations (FDPIR) do not need to list a Social Security number.
Some children qualify for free meals without an application. Please contact your school to get
free meals for a foster child, and children who are homeless, migrant, or runaway.

Return completed form to your child’s school.

Household size

Date

Eligibility
Reduced

Denied

Verifying Ofcial’s Signature

Date

The contact information below is solely to fle a complaint of discrimination
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited
from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or
retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require
alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the
responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the
Federal Relay Service at (800) 877-8339.
To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can
be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (866) 632-9992, or by
writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged
discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights
violation. The completed AD-3027 form or letter must be submitted to USDA by:
*MAIL:

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

FAX:
EMAIL:

(833) 256-1665 or (202) 690-7442; or
[email protected]

*Do not mail applications
to this address,
only complaints of
discrimination.

This institution is an equal opportunity provider.