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

7 CFR Part 245 - Determining Eligibility for Free & Reduced Price Meals and Free Milk in Schools

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

OMB: 0584-0026

Document [pdf]
Download: pdf | pdf
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

2016-2017 dvFPOTiPOxlEfptEToFxKoFTERtbAFlikYOtIxoFtIxolitIpJ`BtxOFdoRtIpJ`BSJBxjoI
mBpJeBlEfptEToFTetbAFlipJBdvFPOTiPOtdvFSufSufxjoIloB.wEHRSvBSvRkaTOFdERbO (tbFSvRkaSiIbOtjAB).
kWRe reFloBpJBdvFPOTiPOlixmAIPOHFxoNIu , POHFsERdoRkYOPOpFcufdoRkYOPOli 12 toBdoRxPolfKelifKes(A nmAmIA lOFbFtIloIxaToFdERn`FduRSebRv SRKOxjBtbAFtkAI).

dvFPOTiPOxKopqomIA we: “pJBlixxOFwesORwedRo nBdoRmBcufHkORnBlikdORn`ISAdRo -­
hAFtIlifbvF-­
lifSA
lif
SAxjoI,xwemIA tdobRv tdotIE doRnB
bFdFlefn`FloB.”

POHFmEBsOktiI

mEBKiFHRxlEfmefPLiF

POHFmEBliKEktiI

toBTeleF

pJBkYOPOXa.
mAI
tmAIbF

POlitIkWITWx
e PolffdodoRPOHFlix
Flix-­
mAIpJBlixhEFtxOFcotxOF,
hRToFkWfE xkoIdFwe, mAtmAIcAIPLORk
k-­
tIxfEW hEFtjBn`FdORn`IbFtIxoFtIxl
o itIpJB` txOFHAnF` loB.
tIkSoFxaToFxjoIn`FPRbFptETFo welikYOtIxoFtIxolitIpJB` txOFdoRtIpJB` SJBdDlFe xjAIn`FloB.

KoFKa 2

POlixhEFtxOFbF,
POlitIkWIT- hRToFxkoIdFwe,
WexPolf
cAIPLORkWEfhEF

mBnoFtIloBplOfHRdoRnBKelif

KoFKa 1

dvFPOTiPO (pFcufdoRnB) tjBjABtjBjABNufloBmBHkORtIlitImBSiBtIreFtIkLBe tmEBmAtmAIxan`ItmEBdDtIpOfTWx
e KE: SNAP, TANF, mAtmAI FDPIR n`FXa.
tIjAIxnoFjEI

mAItImAIdoR > kWRe loBtIjAIxnoFjEIPexBE wEBdoRleBliqasvKFo Ka 4 (tmBpJBe ToFKoFKa 3 tjAB)

mAItmAIbFn`F > leBsvqasvKFo Ka 3 tkAI.

kWRe noFtIjAInoFjEITetKaXOBlitIloIPexBE n`FloB.

KoFKa 3

pfPLaToFdvFPOTiPOxSAhNe fu KelifKes(A leBptfKoFKaxEBdoRnmAmIA SERsi ’mAI’ n`FleBsvqasvKFo Ka 2)
pJeBbLoleF

k. POSAheNuf

POSh
A Ne fu

tbLotbLoPOHFlidvFPOTiPOxpvBdORn`ImAtmAImBn`IbFkLOFSAn`FloB. dvFPOTiPOlitIkWeRnoFloBxoBliKoFKa 1 xpvBKelifKesAn`FwEHRSvBduRpfcufxSAheNuflitIdORn`IbFxoBPexEBtkAI.

kORNWdE Re

kORKENdEW Re

tlaKEbLo tlatbLo

$

K)pJBdOFtufKOFpJeBKelifKesAlidvFPOTiPOxpvB (pFcufdoRnnoIkSIdFwe)
SAhNe fu tkluflitIpFcufxoBPexBE n`
FntHAFqaXa.
tIkSoFxaToFxjoImBcFkdakbLRE p
BdoRkWIkdakABkABlEftOBPLalixmAI“SA
heNfu tIloIPelFe ”xjAIn`FloB.

kWeRreFloBdvFPOTiPOlitbFtIkWeRloBdERxoBliKoFKa 1 xpvB (pFcufdoRnnoIkSIdFwe) xweHAFmAmAItdORn`IbFkLOFSAdFleFn`FloB. dvFPOTiPOlitIkWeRloBxoBtjBSufSuf, mAmAIxweHAFdORn`IkLOFSAdoRpfPLaToFxSAheNufKelifKesA (SAheNufKelifKesApfPJOFtKLURtITuRk­
WEfKOFHWexKa)KoPLOSAdolFxlixpJeB (tduRpFfcufdoRSe(T)tkvftjAB).mAmAISAheNuftxOFnotmEBbFxKa, kWeRnoF “0” lixloIn`FloB. mAmIA nkWeRloB ‘0’ mAtmAItkWeRloBtInotmEBbFn`FnxiFloBtvIlOf (xiFloB) wedFlintbFpfPLaToFSAheNufnotmEBbFn`FloB.

lEftOBPLa
“POHFdORn`ISAhNe fu tIloIPelFe ”
kmBSiBnBlinkmBpJBe tInoFPRlixmAI
wePOSh
A Ne fu n`FloB.
lEftOBPLa
“pJBdOFtufKOFpJBe dORn`ISAhNe fu tIloIPelFe ”
kmBSiBnBlinkmBpJBe tInoFPRlixmAI
wepBJ dOFtufKOFpJBe SAhNe fu n`FloB.

dvFPOTiPOKelifKesA
(POHFdoRpJBdOFtufKOFpJeB)

KoFKa 4

SAhNe fu lipJBkmLiItImBSiB/tIluIxoFluIxoPOxbvRxle/kLOFSAlit­
IdORn`IxoBlimamt
A mAIwBliqatjB

pJeBbLoleF
pJBdOFtufKOFpJeBKelifKesAxmEBlidvFPOTiPOxpvB (mEBsOktiIdoRKEktiI)

tImBxbvRxle

kORNWdE Re

kORKENdEW Re

tlaKEbLo tlatbLo

pJeBbLoleF
kORNWdE Re

kORKENdEW Re

pAFSAF/tIn`IbFkLOFSAPt
e IxOFbJRE ­
litImB/SAhNe fu xjuBxjuBKelifKesA

tlaKEbLo tlatbLo

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

pJBlixSAheNufdOFktiItjBmAtmAIpJBdOFtufKOFpJeBlidvFPOTiPOxjBtjBxsOzeBSKireTE
(Social Security SSN)noFjEIliKEktiIlWEIPLiF

X

X

X

X

X

pJeBbLoleF
kORNWdE Re

kORKENdEW Re

tlaKEbLo tlatbLo

mAmAIsOzeBSKireT (SSN) txOFbFdoRmBnoFtI

tIseRkLORxjAIxkLOBdoRpJBdOFtufKOFpJBe xtIseRloBmEB

“yxiFloBtvIlOf (xiFloB) li tIkSoFpFcfwedFlilEfptEToFxEBmAIwetowedoRykWeRPLaToFweSAheNufKelifKesAn`FloB. ynIpiIbFwelitIkSoFliyhAFPLaToFbFTWelOfHRdoRkLOFSAlikoISiPJOFhAFlitImBSiBxjoIdoRpJBKOFpJBnIPekYOHmEHmORkWI (mBkWI) tIkSoFxjAIKelifHAn`FloB. yHAFqawedFlimAmAIyhAFtIkSoFlixkmFn`FymBloB­
mIkWEfyPOxtIxoFtIxoxbLURxPJOFHA, doRtIlOfkWoIyBliHeSRdoRkoISiPJOFxtIHOFtIHoxPolfHAn`FloB.”

tIxOFsORxnoFjEI (mAItImBn`IxoBHA)

pJBdOFtufKOFpJeBliseRloBxmEBlilEfptEToFtIkWeRloBmEB

hEFdiRPJOFnoFjEI

wAI

pJBdOFtufKOFpJeBxtIseRloBmEB

koISeF

SER(p)

joBKoloteSOdoRlopri (litIcuTixoBHA)

tnEBxEBxmuInEBmuIHo

tIHOFlOneFlOtPF

SAhNe fu tIloIPelFe

POSAheNuftIloIPeleF

pJBdOFtufKOFpJeBSAheNuftIloIPeleF

- tImBxbRxle

- POmBtImBlitIsiktoIlipJeB mAtmAItIsiktoI
KoPRdoRPexwedORn`ItImBxbvRxlemAtmAIkLOFSA

- pJBjAIwotIxERTWekWITWe
- noIKOkAIjoBtsvFxbvRxle
- pJBlixOFmvtAIdERxtIbLURtIPJOF

- POmefbLoFmAtmAInoIKOkAIjoBtsvFdoRdORn`IbFpJBjAIwotIxER
TWekWITWetIbLURtIPJOF
- mOIpIlixnoIKOFkAIjoBtsvF, xOFbJERlitImBmvda,
mAtmAIHEtAIlE, doRxPOdORn`IbFpJBjAIwotIxERTWekWITWet
IbLURtIPJOFtPF

- SAheNufKoPLOpJBlinhEFKLixcO

- tEBHkORmAtmAIdvFPOTiPOxjuBxjBliqoNuIhAFwePOHF
tjBkLOFSAlitIpJ`BtIxjoI

- SAheNuflitIloIxjuBxjB

- POHFdORn`IbFkLOFSATobOlixkSIpAFSAF, tIdORn`IbFSAl­
itnEFxjoItnEFxjoI, mAtmAISApfkoB

tIcuTixoBHA

tImBxbRxle

xdO(tPF)

POSAheNuftIloIPeleF

pJBkmLiItImBSiB/kLOFSAlitIdORn`IxoBlimamAtmAIwBliqatjB/tIluIxoFluIxoPOxbvRxle

- tImBxbvRxle, tImBn`IkLOFSA,
tIhAFxaToFlale
- nnokSIdFwetImBxSAlixxOFloBtef­
PetITuRToFkWEftIlifKelifwEBxloIKE
(tImBweBxloImAtmAItImB)

- tIhAFtIPERtImBtn`IxtIbLUR
tIPJOFtPF
- tIhAFmBSiBkABpJBmBtIPO
- pJBjAIwotIxERTWekWITWelixpfPJOFxaToFSAheNuf (SSI)
- kLOFSAtImBSiBlikoISeFmAt­
mAmAInbFTWedoRxmerkBHuRmuIn`F:
mAIkoIpdOFlinloIkwoBpvB
- kLOFSAlitIdORn`IxoBlimamAtmAIwBli
- tIxbvRxledoRtIhAFkLOFSAxaToFlale qatjB
(tduRpFcufduRtIyBtIxbvRxle,
- kLOFSAlitIdORn`IlitIkWITWePOxjoI
FSSAmAtmAIkLOFSAlitIpfKvHvFtIx- pJBlixmAItAIHuRPOxtIbLURtIPJOF
OFsORloIxjoItjAB
- pJBmBtIPOsOktoItImBmokOfPOxtIbLUR­
- kLOFSAlintIxOFsORloIliHuRmuIxKLi,
tIPJOF
tIxoFtIxodoRtIkvRtIkBxjoI

pAFSAF/tInAIbFkLOFSAPetIxOFbJERlitImB/SA­
heNufxjuBxjuB
- pJBjAIwotIxERTWekWITWe
(pFcufdoRtIxOFbJERlilAFmAFxvkLex­
tImBdoRpHOFHvxtIbLURtIPJOF)
- nnoIkSIpAFSAFmAtmAItIhAFmBSiBpJB­
noIKOFkAIjoBtsvFxtIbLURtIPJOF
- SAheNufTobOliSApfkoBdoRmAtmAItISu­
loIKoFKOF
- SAlitImBn`IkABxoBtnEFtbLo
- SAheNuflitIbLiloBSAmOIpJI
- SAxxAF
- SAheNuflihEFle
- kLOFSAheNufqoNuIlinhEFncoxKLi

POxklufdvFdoRklufxjAIxkLOB

tIlOFbFpJBlitIcAnBnPOklufdvFdoRklufxjAIxkLOBxjoIn`FloB. tIkSoFxjAIxkLOBxEBlixrAdOFdoRmBSiBpJBlipkhAFtImBSiBlilipJeBpJeBliloIkwoBpvBxEBn`FloB. litInoBPRxEBxpvBntISERsikABpJBmAInnoFkSIxtIcuTidoRtmBbFdOFnPOxtIKWeRtIyflitIxoFtIxolitIpJ`BtxOFmAtmAItIpJ`BSJBn`FbF.
kluf (mBnoFtKa):
SpAFTvlEBPOmAtmAIleRtAFPO
tmAISpAFTvlEBPOmAtmAIleRtAFPObF

pJBxAziFPO
kluFdvF (mBnoFtKamAtmAIxan`ItKa):
pJBxAdyaPOmAtmAIpJBxilABSKoPO


pJBHvPOmAtmAIpJBxB/PEBkBxmerkBPO

pJBhiwABxEBPOmAtmAIpJBpSERPERPO

pJBwaPERPO

pJBlixnoIKOnoIHRtsvFbFdoRlOFbFtIseRkLORtIloBsolitIreFtIkLeBxjAIxkLOBxjoI (xdO, pJBmeftTEFtIxlEf, lEfmefPLiFlixdOF,
tIPoFcftIkluI, xmerkBpnoFkLOf, doRtIxjuBxjB)n`F, \kiRseRkLORsvtImBKiFSRxloI (koISeFmAtmAIloIkwoB) PexweHAFptEToFtAIwetIbLURtIPJOFtPFn`FloB. pJBlixnItxi, mAtmAIxnIcimAtmAIktOBtItHAxaxabFn`FseRkLORsvUSDAxxOFKoPLOkoISiPJOFKopnEFlidORn`ItIkSoFdoRsJikdoRsvqasvpxOFPe (800) 877-8339 n`FloB. tkRbFxmefqa, tIreFtIkLexjAIxkLOBbFtImBn`IxoBlikLOfx­
an`IdERxeklERkLOfHAn`FloB.

rezoBbEriSeB (Richard B. Russell) kYOmuITvFtIxoFtImBbFcRTEkoIcAwetIjAItIkLOBlilEfptEToFxEBxpvBn`FloB. ntbFhAFtIjAItIkLOBxEBbF,
bFsFmAmAIntmBdDn`FbFdoR, pxiFloBtvIlOfntIptEToFlitIxoFtIxolitIpJ`BtxOFmAtmAItIpJ`BSJBtHAFbF. dvFPOTiPOxpJBdOFtufKOFpJeBlixseR­
loBxmEB lilEfptEToFxEBxPoKOFn`FkbFduRpFcufxSOzeSeKiFrtEf(social security)noFjEIliKEktiIlWEIPLiFn`FloB. SOzeSeKiFrtEf (social security)
noFjEIliKEktiIlWEIPLiFtbFtIhAFxoBlipJBjBxPOmAtmAInpfPLaToFtIjAInoFjEIlitImBxaToFtIxoFn`IjEIn`IbatItOBSiBmBSiBxtIreFtIkLeB(SNAP),
tImBSiBtSOItloIlihEFPOcoPOlixlOFbFtImBSiBxjoI (TANF)tIreFtIkLeBmAtmAItIhAFnoFloBtIxoFtIxolipJBxAdyaPOloIk­
woBxtIreFtIkLeB(FDPIR)mAtmAIFDPIRtIjAInoFjEIxjuBxjBlinPOxjoImAtmAIPenpfPLaToFwedFlidvFPOTiPOxpJBdOFtufKOFpJeBliseRloBmEBlilEfptEToFx
PoKOFtjBn`FtxOFdoRSOzeSeKiFrtEf (social security) bFxKan`FloB. pkSvRkantIkSoFxjAIxkLOBlitIsitefnPOxKWeRxyflitIxoFtIx­
olitIpJ`BtxOFdoRtIxoFtIxolitIpJ`BSJBxjoI, doRpisJidoRmBloBtEIdDHORpJBklvBpOfmBTWemuITvFtIxoFdoRjoBtIx­
oFxtIreFtIkLeBxtIHOFtIHoxjoIn`FloB. bFHAFHAFpkhAFnoFloBntIKWeRtIyfxjAIxkLOBsvtIkvFbFkvFHA, tIkWITWetIxOFsvFxOFKLA,
doRtIn`IjEIn`IbaxtIreFtIkLeBkriPOxxOFdDHORkmBSiBxoBlikHmETE, hAFkLOFSAtImBSiB, mAtmAIsiteftIbLURtIPJOFxjAIlixtIreFtIkLeBxjoI,
tkRbFxmefqabFHAFHAFpkhAFnoFloBntIjAItIkLOBsvpJBHmEHmORtIreFtIkLeBxlEfSroptoI, doRHeSRpJBKOFpJBnIdDHORkmBSiBxweHAFHmETEtImB­
kmFtIdoRmBliToFpJeBToFtIreFtIkLeBxtIHOFtIHotPFxjoIn`FloB.

tIsJORToFtIkWImeftIreFloBkLeBloBxjAIkHAxjoIn`FmBpJeB USDA lEfptEToFlitIsJORToFtIkWImefxjoI (AD-3027)
litITEFn`IxoFPe http://www.ascr.usda.gov/complaint_filing_cust.html, doRPe USDAweBdiRtpvBjABtpvBjABHA, mAtmAIkWeRloBlEfpritbAFdoRsJixoBsvUSDAxxOFdoRduRpFcuflEfptEToFxtIcAToFxjAIxkLOBKeliflixpvBn`FloB. tIcAtIsJORToFtIptEToFxEBxjoI, seRkLORloteSOsv (866) 632-9992 tkAI. lEfptEToFmAtmAIlEfprilinmBpJeBToFn`FhAFToFxoBsvUSDAxOFKoPLO:
U.S. Department of Agriculture

sJilEfprisv:

Office of the Assistant Secretary for Civil Rights

tIbFTWelOfdoRHeSRxtIHOFtIHolipJBkmLiIxtIKWeRtIyftPFdoRxmerkB­
tIHvFtIPLRkri(USDA)xtIHOFtIHotIbLilipJBkmLiIxtIKWeRtIyftPFxjoIn`F(USDA), KiFSRkri, weBdiR, doRxpJBmBtIPO, doR tIkrikrO­
lipFcufmBHkORtI mAtmAIpisJi(USDA) tIreFtIkLetPFn`F ntINufloBmBHkORtI doRpJBkmLiI tIKWeRtIyfxtIreFtIkLe mAtmAItIPERtImBli
USDA pisJimAtmAIhAFkLOFSAtImBSiB lixjoIn`F tItpefPRnoBPRnBlinklufdvFmAIjAB, tIxlWeImAijAB, TEkoImAIjAB, muFKWa mAIjAB, noIKOFnoIHR
kAIjoBtsvFmAIjAB, HRxOFTeleFmAIjAB, mAtmAItImBkF sikABtI doRtIhAFkFtImAIjAB xPoKOFbFn`FloB.

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

(202)690-7442; mAtmAI

sJiloprisv:

[email protected].

tIkrikrOxEBhAFloBtIKWeRtIyfTeHORtuBHORdoRpJBjBloB.

tmBpJeBToFtjAB

TedFkYOHt
v IHA

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


File Typeapplication/pdf
File TitleSchool Lunch Prototype App_Karen
File Modified2023-07-13
File Created2016-05-20

© 2024 OMB.report | Privacy Policy