Household - 7 CFR 245

Attachment J26. Prototype Household Application for Free and Reduced Price School Meals (Karen)
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

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U.S. Department of Agriculture

sJilEfprisv:

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1400 Independence Avenue, SW
Washington, D.C. 20250-9410
PeRnoFjEI

(202)690-7442; mAtmAI

sJiloprisv:

[email protected].

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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