Household - 7 CFR 245

Attachment J19: Prototype Household Application for Free and Reduced Price School Meals (Hmong)
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: XX/XX/20XX

2016-2017 Qhov Xub Muaj Daim Ntawv Thov Kom Tau Noj Tsev Kawm Ntawv Cov Zaub Mov Dawb Thiab Txo Tus Nqi Caij So
Sau kom tiav ib daim ntawv thov tauj ib yim neeg. Thov siv cwj mem (tsis yog mem qhuav).

Sau TXHUA tus menyuam mos, menyuam yaus, thiab cov tub ntxhais kawm mus txog thiab suav nrog qeb 12 puav leej yog cov neeg hauv yim neeg
(yog xav tau chaw ntau ntxiv loss au cov npe muab lwm daim ntawv coj los ntxiv rau.)

Qhov ntsiab lus ntawm Cov Neeg
Hauv Yim Neeg: “Txhua tus neeg uas
nrog koj nyob thiab koom cov nyiaj
khwv tau los thiab koom siv nyiaj,
txawm tsis cuam tshuam los xij.”

Menyuam Thawj Lub Npe

MI

Menyuam Lub Xeem

Qeb

Cov menyuam nyob hauv Chaw Tu
thiab cov menyuam uas ntsib qhov
txhais ntawm Tsis Muaj Tsev Nyob, Ib
Sij Tsim Chaw Mus Ntiav Zog Ua
lossis Khiav Tawm Ntawm Tsev tsim
nyog rau zaub mov dawb. Nyeem Seb
Yuav Mus Thov Li Cas Thiaj Dawb
thiab Txo Cov Nqe Tsev Kawm Cov
Zaub Mov rau lwm cov lus qhia ntxiv.

KAUJ RUAM 2

Menyuam Ua, Khiav Tawm
Txais Los Tu Ntawm Tsev

Koj tsev neeg (suav koj tus kheej) tam sim no puas koom nrog ib lossis ntau dua los ntawm qhov kev pabcuam no: SNAP, TANF, lossis FDPIR?
Yog TSIS YOG

Case Naj Npawb:

Yog YOG > Sau ib tug case naj npawb no ces mus rau KAUJ RUAM 4
(Tsis txhob ua KAUJ RUAM 3)

> Mus rau KAUJ RUAM 3.

Sau tib tug case naj npawb hauv qhov chaw no.

Qhia cov nyiaj khwv tau los rau TXHUA tus nyob hauv tsev neeg (Hla qhov kauj ruam no yog hais tias koj teb tias ‘YOG’ mus KAUJ RUAM 2)

KAUJ RUAM 3

A. Menyuam Cov Nyiaj Khwv Tau Los
Tej zaum cov menyuam hauv koj yim neeg khwv tau lossis txais cov nyiaj los. Thov qhia cov nyiaj TAG NRHO khwv txais los ntawm

tag nrho yim neeg sau hauv KAUJ RUAM 1 no.

B. Tag Nhro Cov Neeg Loj Nyob Hauv Tsev Neeg (nrog rau koj tus kheej)
Koj tsis paub meej tias nyiaj
khwv tau los yog dab tsi
yuav muab tso no?

Menyuam Cov Nyiaj
Khwv Tau Los

Nquag tau txais npaum cas?
Ib Asthiv

Ob-Asthiv

2x Hlis

Ib Hlis

$

Sau txhua tus neeg hauv tsev neeg uas tseem tsis tau muaj npe hauv KAUJ RUAM 1 (suav nrog koj tus kheej) txawm lawv tsis tau txais nyiaj khwv tau los los xij. Rau txhua tus muaj npe hauv tsev neeg, yog lawv tau txais
nyiaj khwv tau los, hais qhia tag nrho cov nyiaj khwv tau los ntawm txhua qhov kev khwv nyiaj ua nyiaj ntsuab tag nrho xwb. Yog lawv tsis tau txais nyiaj khwv tau los los ntawm ib qho twg, sau ‘0’. Yog koj sau ‘0’ lossis
tsis sau dab tsi rau ib qho twg, koj yuav tau lees paub (cog lus) tias tsis muaj nyiaj khwv tau los.
Kev Pab Cuam Neeg Pej
Xeem/Cov Nyiaj Pab Cuam
Menyuam Yaus/Pojniam Uas
Nrauj Lawm

Nquag tau txais npaum cas?

Lub Npe Ntawm Tus Neeg Loj Hauv Tsev Neeg
(Npe thiab Xeem)

Tig sab phab thiab xyuav
cov kab kos hu ua “Los
ntawm cov nyiaj khwv tau
los” rau cov lus qhia ntxiv.

Tau Txais Los Ntawm Haujlwm

Ib Asthiv

Ob-Asthiv

2x Hlis

Ib Hlis

Nyiaj Laus/Nyiaj So
Haujlwm/Lwm Yam

Nyiaj Khwv Tau Los

Nquag tau txais npaum cas?
Ib Asthiv

Ob-Asthiv

2x Hlis

Ib Hlis

$

$

$

Cov ntawv qhia “Los ntawm
cov nyiaj khwv tau rau
menyuam” yuav pab koj
nrog seem menyuam cov
nyiaj khwv tau los.

$

$

$

$

$

$

Cov ntawv qhia “Los ntawm
cov nyiaj khwv tau rau neeg
loj” yuav pab koj nrog seem
Tag nrho cov neeg loj nyob
hauv yim neeg.

$

$

$

$

$

$

KAUJ RUAM 4

Tsis Muaj Tsev Nyob,
Ib Sij Tsim Chaw
Mus Ntiav Zog

Menyuam kawm
ntawv?
Yog
Tsis Yog

Khij tag nrho uas siv

KAUJ
RUAM 1

Tag Nrho Cov Neeg Hauv Tsev Neeg
(Cov Menyuam Yaus thiab Cov
Neeg Loj)

Plaub Tus Lej Tom Qab ntawm Tus Lej Xaus Saus (SSN)
ntawm Cov Nqi Zog Thaum Pib lossis Lwm Tus Neeg
Loj Hauv Tsev Neeg

X

X

X

X

X

Nquag tau txais npaum cas?
Ib Asthiv

Ob-Asthiv

2x Hlis

Ib Hlis

Xaiv yog tsis muaj SSN

Cov ntaub ntawv tiv toj thiab tus neeg loj kos npe

“Kuv lees paub (cog lus) tias txhua cov ntaub ntawv ntawm daim ntawv thov no yog qhov tseeb thiab tau hais qhia txhua qhov nyiaj khwv tau los. Kuv nkag siab tias cov ntaub ntawv no tau muab raws li kev txuas nrog qhov tau txais Tsoomfwv cov peev nyiaj, thiab cov tsev kawm ntawv ntawd
yuav lees paub (kuaj xyuas) cov ntaub ntawv raug cai. Kuv paub tias yog kuv txhob txwm muab cov ntaub ntawv tsis raug, kuv cov menyuam yuav plam cov kev pab zaub mov, thiab kuv yuav raug lub txim raws li Lub Xeev thiab Tsoomfwv cov kev cai lij choj.”

Chaw Nyob (yog muaj)

Apt #

Luam lub npe ntawm tus neeg loj kos npe ntawm daim foos no

Lub Zos

Kos npe ntawm tus neeg loj

Lub Xeev

Zip

Tus Xov Tooj Hu Nruab Hnub thiab Email (xaiv tau)

Hnub tim hnub no

LUS QHIA

Los ntawm cov nyiaj khwv tau los

Los ntawm cov nyiaj khwv tau rau neeg loj

Los ntawm cov nyiaj khwv tau rau menyuam

Nyiaj tau los ntawm hauj lwm

Piv txwv

Los ntawm cov menyuam cov nyiaj khwv tau los

- Ib tug menyuam muaj ib txoj haujlwm uas ib hnub
lossis ua ob peb xoos moos uas lawv tau nyiaj hli
lossis nyiaj xoos moos
- Ib tug menyuam dig muag lossis xiam oob qhab
thiab txais nyiaj xaus saus
- Ib leej niam leej txiv xiam oob qhab, so, lossis
tuag, thiab lawv cov menyuam txais cov nyiaj xaus
saus

- Nyiaj tau los ntawm ua haujlwm
- Xaus Saus
- Them rau xiam oob qhab
- Cov neeg tseem nyob cov nyiaj
pab
- Nyiaj khwv tau los ntawm tus neeg sab
nraud tsev neeg

- Ib tug phoojywg lossis tsev neeg sib
txheeb nquag muab nyiaj siv rau tus
menyuam

-N yiaj khwv tau los ntawm lwm qhov chaw

- Ib tug menyuam txais cov nyiaj hli ib txwm
los ntawm cov nyiaj laus tshwj xeeb, nyiaj
xyoo, lossis nyiaj khaws cia

XAIV TAU

- Nyiaj hli, nyiaj xoos moos,
nyiaj ntsuab tshwj xeeb
- Nyiaj hli nqa los ntawm yus
tus kheej txoj haujlwm (ua teb
lossis ua lag luam)
Yog tias koj nyob hauv lub teb
chaws Asmeslikas tsov rog:
- Them nyiaj li qub thiab nyiaj
ntsuab tshwj xeeb (tsis TXHOB
suav cov nyiaj them tauj, FSSA
lossis nyiaj pab tsev nyob)
- Nyiaj rau cov tsev tawm, zaub
mov thiab khaub ncaws

Kev Pab Cuam Neeg Pej Xeem/Cov Nyiaj Pab Cuam
Menyuam Yaus/Pojniam Uas Nrauj Lawm

- Nyiaj poob haujlwm

- Nyiaj ua haujlwm
- Nyiaj xaus saus (SSI)
- Pab nyiaj ntsuab los ntawm
lub xeev lossis tsoom fwv qhov
chaw
- Nyiaj them
- Them pab yug menyuam
- Tub rog cov nyiaj pab
- Nyiaj pab cuam

Nyiaj Laus/Nyiaj So Haujlwm/Lwm Yam Nyiaj
Khwv Tau Los

- Xaus saus (suav nrog cov
nyiaj so kev tsheb ciav hlau
thiab nyiaj pab mob ntsws
dub)
- Nyiaj laus tshwj xeeb lossis
xiam oob qhab
- Nyiaj ib txwm tau los
ntawm cov nyiaj tseg lossis
qub ntxeeg
- Nyiaj xyoo
- Nyiaj peev
- Nyiaj tau paj
- Nyiaj xoj tsev
- Nyiaj ntsuab them los
ntawm sab nrauv tsev neeg

Cov Cim Ntawm Menyuam Haiv Neeg thiab Pawg Neeg

Peb yuav tsum tau nug cov ntaub ntawv txog tus menyuam haiv neeg thiab pawg neeg tsawg. Cov ntaub ntawv no tseem ceeb thiab pab kom ntseeg tias peb tau muab kev pab rau
peb lub zej zog tau zoo. Kev teb rau ntu lus no yog xaiv tau thiab tsis muaj kev cuam tshuam txog koj tus menyuam qhov muaj feem tau txais zaub mov dawb lossis txo tus nqi.
Haiv neeg dab tsi (xaiv ib qho):
Neeg Mev lossis Latino
Tsis Yog Neeg Mev lossis Latino
Race (check one or more):
Neeg Qhab lossis Keeb Kwm Alaska
Neeg Es-Xias
Neeg Tawv Dub lossis Neeg Asfibkas Asmeskas
Sab Hnub Tuaj
Neeg Tawv Dawb

Cov neeg xiam oob qhab uas lawv yuav tsum muaj lwm txoj hauv kev los sib txuas lus txog txoj kev pabcuam no (xws li
Cov Ntawv Rau Cov Neeg Dig Muag, cov ntawv uas luam kom cov tsiaj ntawv loj pom tseeb, cov kaw suab lus, Lus Piav
Tes Meskas, thiab lwm yam) yuav tsum hu xovtooj rau Lub Chaw Dhia Dej Num (hauv Lub Xeev lossis hauv ib cheeb tsam)
uas lawv mus sau npe thov tej txiaj ntsig kev pab. Cov neeg lag ntseg, hnov lus tsis zoo lossis hais lus tsis taus, hu xovtooj
mus rau lub chaw USDA siv qhov kev hu xovtooj hu ua Federal Relay Service ntawm (800) 877-8339. Tsis tas li no xwb,
tej zaum cov ntaub ntawv no tseem muaj sau ua lwm hom lus uas tsis yog lus Askiv thiab.
Yog xav tso ntawv tsis txaus siab txog kev ntxub ntxaug hauv txoj kev pabcuam no, muab Daim Ntawv Sau Npe Tsis Txaus
Siab Txog Kev Ntxub Ntxaug ntawm lub chaw USDA ua kom tiav, (AD-3027) rau hauv online ntawm: http://www.ascr.us­
da.gov/complaint_filing_cust.html, thiab xa coj mus rau ib lub chaw dhia dej num USDA twg los tau, lossis sau ib tsab
ntawv mus rau lub chaw USDA thiab sau rau hauv tsab ntawv qhia txhua nqais lus uas tau thov nyob hauv daim ntawv
sau npe tsis txaus siab. Yog xav thov ib daim ntawv theej ntawm daim ntawv sau npe tsis txaus siab, hu rau (866) 632-9992.
Xa koj daim ntawv ua tiav lossis tsab ntawv mus rau USDA raws li:

Tsab cai Richard B. Russell National School Lunch Act xav tau cov ntaub ntawv ntawm daim ntawv thov no. Koj tsis tas
yuav tsum muab cov ntaub ntawv no, tab sis yog koj tsis muab cov ntaub ntawv no, peb tsis tuaj yeem pom zoo koj tus
menyuam kom tau txais zaub mov dawb lossis txo tus nqi. Koj yuav tsum muaj plaub tus lej tom qab ntawm tus lej saus
saus (SSN) ntawm tus neeg loj hauv yim neeg uas kos npe daim ntawv thov no. Tsis xav tau plaub tus lej kawg ntawm
tus lej neeg txom nyem yog thaum koj thov sawv cev rau tus menyuam tu los yog koj muaj npe Chaw Haujlwm Pab cuam
Khoom Noj Muaj Txiaj Ntsig Ntxiv (SNAP), Kev Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance
for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) tus lej thov lossis lwm
yam xaiv FDPIR rau koj tus menyuam lossis thaum koj qhia tias tus neeg loj hauv yim neeg uas kos npe hauv daim ntawv
thov tsis muaj tus xaus saus. Peb yuav siv koj cov ntaub ntawv los txiav txim siab seb koj tus menyuam puas muaj feem
tau txais zaub mov dawb lossis txo nqi qis, thiab rau kev tswj hwm thiab yuam kom muaj kev pab pluas su thiab pluas
tshais. TEJ ZAUM peb yuav nthuav tawm koj cov ntaub ntawv muaj feem txhawm rau kev kawm, noj qab haus huv, thiab
pab cuam zaub mov muaj txiaj ntsig zoo txhawm rau pab lawv ntsuas, nyiaj txiag, lossis txiav txim siab cov kev pab rau
lawv cov haujlwm, cov neeg kuaj xyuas txoj haujlwm, thiab yuam kev ua haujlwm raws kev cai lij choj kom pab lawv saib
mus rau kev yuam cov cai.
Raws li Tsoomfwv txoj cai lij choj teev cov cai uas txhua tug tib neeg muaj thiab cov cai tswjfwm thiab kav cov cai txhua
tug tib neeg muaj ntawm Tsoomfwv Meskas Qhov Chaw Tuav Dej Num Rau Phab Kev Ua Liaj Ua Teb Tu Tsiaj Yug Txhuv
(USDA) , lub chaw tuav dej num USDA, nws cov chaws dhia dej num, chaw ua hauj lwm, thiab cov neeg ua hauj lwm, thiab
cov tuam txhab uas koom nrog lossis dhia dej num rau USDA cov kev pabcuam raug txwv kom tsis pub muaj kev ntxub
ntxaug txog ib tug neeg los ntawm saib nws yog haiv neeg dab tsi, neeg ngaij tawv dab tsi, txivneej lossis yog pojniam,
neeg xiam oob qhab, muaj hnub nyoog laus lossis hluas, lossis ib qho dej num uas ua tiav lossis tau txais nyiaj txiag txhawb
los ntawm USDA los.

Tsis txhob sau ntu no

Keeb Kwm Hawaii lossis Lwm

xa hauv tsev xa ntawv: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410
xa hauv fax:
(202) 690-7442; lossis
xa hauv email:
[email protected].
Lub chaw haujlwm no yog ib lub chaw muaj cib fim sib luag rau txhua tug neeg.

Nov yog rau tsev kawm siv nkaus xwb

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