Attachment K. Prototype Application Instructions

Attachment K: Prototype Application Instructions
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 read this information and 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

How To Apply for Free and Reduced Price School Meals
Please use these instructions to help you fill out the application for free and reduced price school meals. You only need to submit one
application per household, even if your children attend more than one school in the [Insert School District].
The application must be filled out completely to determine the eligibility of your child(ren) for free or reduced price school meals.
Please follow these instructions in order! Each step of the instructions is the same as the steps on your application. If at any time you
are not sure what to do next, please contact [Insert school/school district contact here; phone and email preferred].
Please use a pen (not a pencil) when filling out the application and do your best to print clearly.

Step 1: List ALL children, infants, and students up to and including grade 12
Tell us how many infants/toddlers, children not in school, and elementary/middle/high school students live in your household. They do NOT have to be related to
you to be a part of your household.
Who should I list here? When filling out this section, please include ALL members in your household who are:
• Children age 18 or under AND are supported with the household’s income;
• In your care under a formal foster arrangement through a court or state/local agency, or qualify as homeless, migrant, or runaway youth;
• Students attending (regardless of age) [school/school system here].
A) List each child’s name. Print
each child’s name. Use one line
of the application for each child.
When printing names, write one
letter in each box. Stop if you run
out of space. If there are more
children present than lines on the
application, attach a second piece
of paper (or a second application
if completing electronically) with
all required information for the
additional children. This also
applies to adults in Step 3. “MI” is
short for middle initial. Print the
first letter of each child’s middle
name in the box.

B) Is the child a student?
If “Yes,” write the grade
level of the student in the
“Grade” column to the right.

C) Do you have any foster children? If any
children listed are foster children, mark the
“Foster Child” box next to the child’s name. If
you are ONLY applying for foster children, after
finishing Step 1, go to Step 4.

D) Are any children homeless, migrant, or
runaway? If you believe any child listed in this
section meets this description, mark the
“Homeless, Migrant, Runaway” box next to the
child’s name and complete all steps of the
application. Homeless, Migrant, Runaway status
Foster children who live with you may count as must be confirmed with the appropriate program
members of your household and should be
staff. If the school district cannot confirm your
listed on your application. If you are applying
student’s homeless, migrant, or runaway status,
for both foster and non-foster children, go to
then the school district will contact you to
Step 3. Note: Adopted children are not
complete an income-based application. You may
considered foster children. A foster child is a
choose to provide income information now in
minor child who has been taken into state
order to prevent the school district from
custody and placed with a state-licensed adult, potentially needing to contact you later.
who cares for the child in place of their parent
or guardian.

This institution is an equal opportunity provider.

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Step 2: Do any household members currently participate in SNAP, TANF, or FDPIR?
If anyone in your household (including you) currently participates in one or more of the assistance programs listed below, your children are eligible
for free school meals:
• The Supplemental Nutrition Assistance Program (SNAP) or [Insert State SNAP here].
• Temporary Assistance for Needy Families (TANF) or [Insert State TANF here].
• The Food Distribution Program on Indian Reservations (FDPIR).
A) If no one in your household participates in any of
the above listed programs:
• Check “No” in Step 2 and go to Step 3.

B) If anyone in your household participates in any of the above listed programs:
• Write a case number for SNAP, TANF, or FDPIR. You only need to provide one case number. If
you participate in one of these programs and do not know your case number, contact:
[Insert State/local agency contacts here].
• Go to Step 4.

Step 3: List ALL household members and income for each member
How do I report my income?
• Use the lists titled “Sources of Income” & “Examples of Income for Children,” on the back side of the application form to determine if your household
has income to report.
• Report all amounts in GROSS INCOME ONLY. Report all income in whole dollars. Do not include cents.
o Gross income is the total income received before taxes and deductions.
o Many people think of income as the amount they “take home” and not the total, “gross” amount. Make sure that the income you report on this application
has NOT been reduced to pay for taxes, insurance premiums, or any other amounts taken from your pay.
• Write a “0” in any fields where there is no income to report. Any income fields left empty or blank will also be counted as a zero. If you write “0” or leave any
fields blank, you are certifying (promising) that there is no income to report. If local officials suspect that your household income was reported incorrectly,
your application will be investigated.
• Mark how often each type of income is received using the check boxes to the right of each field.

3.A. Report income earned by adults
Who should I list here?
• When filling out this section, please include ALL adult members in your household who are living with you and share income and expenses, even if they are
not related and even if they do not receive income of their own.
• Do NOT include:
o People who live with you but are not supported by your household’s income AND do not contribute income to your household.
o Infants, children and students already listed in Step 1.

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Step 3: List ALL household members and income for each member
1) List adult household members’ names.
Print the name of each household member in the boxes marked “Names of Adult Household Members (First and Last).” Include college students, unless they
are declared independently on taxes (all college students are considered adults). Do not list any household members you listed in Step 1.
2) List earnings from work.
List all income from work in the “Earnings from Work” field on the application. This is usually the money received from working at jobs. If you are a selfemployed business or farm owner, you will report your net income. Net income is your income after taxes and deductions have been subtracted.
•
•

What if I have multiple jobs? List each job separately by entering your name and income from each job on a new line. Add an additional sheet of
paper if necessary.
What if I am self-employed? List income from your business as a net amount. This net amount is calculated by subtracting the total operating
expenses of your business from its gross receipts (revenue). Gross receipts or revenue are all the income earned from the sale of any products or
services offered.

If a child listed in Step 1 has income, follow the instructions in Step 3, Part B.
3) List income from public assistance/child support/alimony.
List all income that applies in the “Public Assistance/Child Support/Alimony” field on the application. Do not report the cash value of any public assistance
benefits NOT listed on the chart. If income is received from child support or alimony, only report court-ordered payments. Informal but regular payments
should be reported as “other” income in the next part.
4) List income from pensions/retirement/all other income.
List all income that applies in the “Pensions/Retirement/All Other Income” field on the application.
•

What if I receive income from multiple sources in this category? List each source separately by entering your name and income from each
source on a new line. Add an additional sheet of paper if necessary.

5) List total household size.
Enter the total number of household members in the field “Total Household Members (Children and Adults).” This number MUST be equal to the number of
household members listed in Step 1 and Step 3. If there are any members of your household that you have not listed on the application, go back and add
them. It is very important to list all household members, as the size of your household affects your eligibility for free and reduced price meals.
6) Provide the last four digits of your Social Security Number.
An adult household member must enter the last four digits of their Social Security Number in the space provided. You are eligible to apply for benefits even if
you do not have a Social Security Number. If no adult household members have a Social Security Number, leave this space blank and mark the box to the
right labeled “Check if no Social Security Number.”

3.B List income earned by children
List all income earned or received by children.
List the combined gross income for ALL children listed in Step 1 in your household in the box marked “Child Income.” Only count foster children’s income if
you are applying for them together with the rest of your household.
•

What is Child Income? Child income is money received from outside your household that is paid DIRECTLY to your children. Many households do
not have any child income.

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Step 4: Contact information and adult signature
All applications must be signed by an adult member of the household. By signing the application, that household member is promising that all
information has been truthfully and completely reported. Before completing this section, please also make sure you have read the statements on the
back of the application.
A) Provide your contact information. Write your current
mailing address in the fields provided, if this information is
available. If you have no permanent address, that is okay.
Sharing a phone number, email address, or both is optional,
but helps us reach you quickly if we need to contact you.

B) Print and sign your name
C) Mail completed application to:
and write today’s date. Print the
Insert
name of the adult signing the
School/District
application and that person signs
address here
in the box “Signature of adult.”

Optional
Share children’s racial and ethnic identities (optional). On the back of the application, we ask you to share information about your children’s race and
ethnicity. This field is optional and does not affect your children’s eligibility for free or reduced price school meals. This information is requested solely for the
purpose of determining the State’s compliance with Federal civil rights laws, and your response will not affect consideration of your application, and may be
protected by the Privacy Act. By providing this information, you will assist us in assuring that this program is administered in a nondiscriminatory manner.

Please return the application directly to your child’s SCHOOL. DO NOT mail, fax, or email completed applications or
questions about applications to the USDA Office of the Assistant Secretary for Civil Rights or your child’s eligibility for free
or reduced-price meals will be delayed.

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