free_and_reduced_lunch_form

SM-4458-C Rev 5/07

Free and Reduced Price School Meals Family Appl icat ion

use a SEPAMTE application for each FOSTER CHILD

Part 2 - Homeless Migrant I Runaway flI f the chi ld you are apply ing for is homeless, migrant , or a runaway check the appropr iate box and cal l the:

Homeless Liaison or nt Coordinator a

l or The name of ONE Foster Child in school

NewStudent Student's Name School Name Grade

Does your chi ld receive FoodStamps/FIPIFDPIR? If 'YES," you must l ist a

case number.*

: YES t] NO D YES

f YES E N o E Y E S

: YES E N o E Y E S

f YES =1 NO f] YES--1 vtrq - N O F y E S

= YES E N o E Y E S*If Vou listed a Food SIanp/FIP/FDPIR case number for EACH child, skip to Part 5.

Part 4- Total Household Gross Income-You must tel us how much and CIRCLE how often it is received.

NameList everyone in the household

Earnings from work(Before taxes)

Welfare, child support,a l imony

Pensions, retirement,Social Security All other income

Circle i fNO income

Examole lane Doe $100|\/eeklv- s500

Weekly_

;Weekly

D

Weekly

N OMonthly l"lonthl) Month ly Nlonthlt

1

Weekly Weekly Weekiyq

Weekly

N OMonth l \ Monthly Monthly Monthly

2 I

Weekly(

Week ly Weekly Weekly

N Of4onthl\ l.4onthl\ lvlonth l) l ' lonthly

3 t

Weekly Weekly Weekly Weekly

NOf4onthl\ Monthl\ lv lonthly Monthl\

4 $

Weekly(

Weekly Week ly

p

Weekly

N OMonth l \ lv lonthl \ Month ly Monthly

5 $

WeeklyiD

Week ly

sWeekly

D

Weekly

N O! lonth l ! Monthl\ 14onthll lvlonth l\

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Weeklv Weekly Week ly Weekly

N OM onth ly lvlonth I Monthly Monthl\

Weekly

$

Weekly Weekly Weekly

N Olv lonth ly Monthly l .4onthly l '4onthly

pa11 5 - Signature and Socia l Secur i ty Number (Adul t household member must s ign.)If part 4 is completed, the adult signing the form must also l ist his or her Social Security Number or check the "I do not have a SocialSecurity Number" box. (See Privacy Act Statement on the back of this page')

I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get

Federat funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if Ipurposely give fatse information, my child may lose meal benefits, and I may be prosecuted.

Sign Here: Date:

Adult Social Securitv Number: E f ao not have a Social Security Number

Address 3ity Zip Code 3ou nty

Home Phone Work Phone

Do not fill out this part. This is for school use only.Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly xL2

Household Size:_Total Gross Income: $- Week-, Every 2 Weeks-, Twice a Month-, Month-, Annual-

Foster Child:_ Categorical Eligibil i ty:_ Eligibil i ty: Free- Reduced- Denied-

Temporary Free- Time Period:- (expires after-days)Reason for Denial: - Income too High -Incomplete Application -Other (specify)

Date:Off icial 's Siqnature: Date Withdrawn:

1 o f 2

SM-4458-C Rev 5/07

Part 6 - Foster Children In most cases foster children are eligible for free meals regardless of your household income

Foster Home License Number: (opt ional)

_A. The welfare agency or court is legally responsible for the child and the foster home is, in fact, and extension of thewelfare agency or court.

B. The chi ld is a res ident of a l icensed "Group Foster" home or a res ident ia l inst i tu t ion.xxOnly the foster ch i ld 's spending money is counted as income on th is appl icat ion. Do not inc lude money f rom occasional orpar t - t ime jobs l ike paper routes and babysi t t ing. I f you have any quest ions, p lease contact the school .

Par t7 - Chi ld 's Racia l /Ethnic Ident i ty (Opt ional )ies: Check one ethnic ident i tv :

_Amer ican Indian or Alaskan Nat ive -Asian -Hispanic or Lat ino

_Black or Afr ican Amer ican -Whi te -Nei ther Hispanic nor Lat ino

Nat ive Hawai ian or Other Paci f ic Is lander Other

Privacy Act Information: Social Security NumberRichard B. Russel l Nat ional School Lunch Act requires the information on this appl icat ion. You do not have to give the

information, but i f you do not, we cannot approve your chi ld forfree or reduced pr ice meals. You must include the socialsecuri ty number of the adult household member who signs the appl icat ion. The social securi ty number is not required whenyou apply on behalf of a foster chi ld or you l ist a Food Stamp Program, Temporary Assistance for Needy Famil ies (TANF)Program or Food Distr ibut ion Program on Indian Reservat ions (FDPIR) case number or other FDPIR ident i f ier for your chi ldwhen you indicate that the adult household member signing the appl icat ion does not have a social securi ty number, We wi l luse your information to determine i f your chi ld is el ig ible for f ree or reduced pr ice meals, and for administrat ion andenforcement of the lunch and breakfast programs. We MAY share your el igibi l i ty information with educat ion, health, andnutr i t ion programs to help them evaluate, fund, or determine benef i ts for their programs, auditors for program reviews, andlaw enforcement off ic ials to help them look into violat ions of program rules.

Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly

In accordance wi th Federal law and U,S, Department of Agr icu l ture pol icy, th is inst i tu t ion is prohib i ted f rom discr iminat ing on

the basis of race, co lor , nat ional or ig in, sex, age/ or d isabi l i ty , To f i le a compla int of d iscr iminat ion, wr i te to USDA, Director ,

Office of Civil Rights, 1400 Independence Avenue, SW, Washington DC 20250-9410 or call (800) 795-3272 or (202) 720-

6382 (TTY). USDA is an equal opportuni ty prov ider and employer .

Verification - This is for school use only.Date Selected for Verification:_Response Due from Household:Second Notice Sent:_

Sample Select ion:_Focused _Random

BasicFood Stamp/FIP El ig ib i l i ty :

_Not ConfirmedConf i rmed:

_Food Stamp Office

_Not ice of El ig ib i l i ty

_ATP Card issued monthly

Income $__Monthly Yearly_Wage Stubs_Written Documents_Collateral Contact_Agency Records

Other

Verification Result:

_Free to Reduced

_Free to Paid

_Reduced to Free

_Reduced to PaidNo ChanoeReason For El ig ib i l i ty Change:

_Income_Household Size

_Refused to Cooperateother-

Confirming Off ic ial 's Signature :Follow-up Off icial 's Signature :

Date Adverse Notice Sent:

2 o f 2

Dear Parent /Guardian:

Chi ldren need heal thy meals to learn. School(s) offers healthy meals everyschool day. Students may buy lunch for $_ and breakfast for $-, Your children may qualify for free meals or forreduced price meals. We sell reduced price lunches for $- and breakfasts for $-. If a doctor has determined that yourchi ld has a d isabi l i ty , and the d isabi l i ty would prevent the chi ld f rom eat ing the regular school meal , the school wi l l make S$y$ilh"$-trt$$gn*RI:S$Lri.bed Uy $.,s$$q{ at no extra charge, For further information, please callThe doctor's statement, including prescribed diet and/or substitution, must be submitted to the food service department atyour school .

1. Do I need to fi l l out an application for each child? No. Complete the application to apply for free and reducedpr ice school meals. Use one Free and Reduced Pr ice School Meals Fami lv Aopl icat ion for a l l s tudents in yourhousehold. We cannot approve an appl icat ion that is not complete, so be sure to f i l l out a l l requi red in format ion.Return the completed appl icat ion to:

(Name. address, and phone number)

Who can get free meals? Chi ldren in households gett ing Food Stamps, FIP, or FDPIR and most foster chi ldren canget free meals regardless of your income. Also, your chi ldren can get free pr ice meals i f your household income iswithin the free l imits on the Federal Income Guidel ines.

Can homeless, runaway, and migrant children get free meals? Please, homeless l ia ison or migrant coordinator to see i f your chi ld(ren) qual i fy

if you have not been informed that they will get free meals.

Who can get reduced pr ice meals? Your chi ldren can get low cost meals i f your household income is within thereduced pr ice l imits on the Federal Income Chartshown on this appl icat ion'

Should I fi l l out an application if I got a letter this school year saying my children are approved for free orreduced price meals? Please read the letter you got carefully and follow the instructions. Call the school at

i f you have quest ions,(Phone number)

I get WIC. Can my chi ld(ren) get f ree meals? Chi ldren in households part ic ipat ing in WIC may be el igible forfree or reduced pr ice meals. Please f i l l out an appl icat ion.

Will the information I give be checked? Yes, we may ask you to send written proof,

I f I don' t quat i fy now, may I apply later? Yes. You may apply at any t ime during the school year i f yourhousehold size goes up, income goes down, or if you start getting Food Stamps, FIP, FDPIR, or other benefits. If youlose your job, your chi ldren may be able to get f ree or reduced pr ice meals,

What i f I d isagree with the school 's decision about my appl icat ion?You should talk to school of f ic ials. You also may ask for a hearing by cal l ing or wri t ingt ^ '(Name, address, and phone number)

1O. May I apply i f someone in my household is not a U.S. c i t izen? Yes. You or your chi ld( ren) do not have to be aU.S. cit izen to qualify for free or reduced price meals.

11.Who should I inc lude as members of my household? You must inc lude a l l people l iv ing in your household,re lated or not (such as grandparents, other re lat ive, or f r iends) , You must inc lude yoursel f and a l l ch i ldren who l ivewi th you,

12. What i f my income is not a lways the same? Lis t the amount that you normal ly get . For example, i f you normal lyget $1000 each month, but you missed some work last month and only got $900, put down that you get $1000 permonth. I f you normal ly get over t ime, inc lude i t , but not i f you get i t on ly somet imes.

13. We are in the mi l i tary: do we inc lude our housing a l lowance as income? I f your housing is par t of Mi l i taryPr ivat izat ion In i t la t ive, do not inc lude your housing a l lowance as income. Al l o ther a l lowances must be inc luded inyour gross income.

14. What if my child does not have health insurance?Your chi ldren may qual i fy for low cost or f ree heal th insurance through MIChi ld and Heal thy Kids Program. To ApplyOn- l ine, go to www.michigan.gov/michi ld or ca l l 1-888-988-6300 for help or to request a paper appl icat ion.

Sincerely,Letter to Parents5/07 Page 1

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Application Instructions:

Your children may qualify for free or reducedprice meals i f your household income fal lswithin the l imits on this chart .

If your entire household receivesFood Stamps, FIP, or FDPIR, follow theseinstructions:Part 1: Skip this part .

TotalFami ly

S ize Annua l Monthly

Twiceper

Month

EveryTwo

Weeks Weeklv1 $18.889 $ 1 . 5 7 5 $788 5727 $3642 s25.327 $ 2 . 1 1 1 $ 1 .0s6 $97s $4883 $ 3 1 , 7 6 5 $2,648 sL.324 5L.222 $61 14 $38.203 $3 .184 $ 1 .592 $r ,470 $7355 $44,64t $3 ,72L $ 1 .861 st,777 $859o $51 .079 s4,257 $2,t29 $ 1 .965 $9837 $57,577 $4,794 $2,397 s2.2t3 $ 1 .1078 $53 .955 $5.330 s2,665 $2,460 $ 1 .230

*For eachadd i t iona IhouseholdmemDera d d :

$ 6,438x $ 537x $ 269* $ 248* $ 124*

Part 2: Skip this part ,Part 3: I f the student is new to the distr ict /school check"Yes." List student(s) name, school, grade, check"Yes," and l ist a

case number.Part 4: Skip this part .Part 5: Sign and date the form. A social securi ty number is not necessary'Part 7: Answer this question if you choose to.

I f you are applying for a homeless, migrant, or runaway chi ld check the appropriate box and contact your Homeless Liaison orMigrant Coordinator, Fi l l out appl icat ion by fol lowing instruct ions for ALL OTHER HOUSEHOLDS.

If you are applying for a FOSTER CHILD, follow these instructions:Part 1: Check the box and l ist the chi ld 's personal use monthly income, i f any.Part 2: Skip this part ,Part 3: Use a separate appl icat ion for each foster chi ld. List the chi ld 's name, school, and grade'Part 4: Skip this part .Part 5: Sign and date the form. A social securi ty number is not necessary.Part 6: Answer this quest ion i f you choose to,Part 7: Answer this quest ion i f you choose to,

ALL OTHER HOUSEHOLDS, including WIC households, fol low these instruct ions:Part 1: Skip this part .Part 2: Check the appropriate box, if any.Part 3: I f the student is new to the distr ict /school check "Yes." List each student(s) name/ school, and grade.Part 4: Follow these instructions to report total household income from last month.

Column 1- Name:. List the f i rst and last name of each person l iv ing in your household, related or not (such as grandparents, other

relat ive, or f r iends). You must include yourself and al l chi ldren l iv ing with you. Attach another sheet of paper i f youneed to.Column 2- Gross Income:

. Next to each person's first and last name list each type of income received last month. Next to the amount circle howoften the person oot i t (weeklv, everv otherweek, twice a month, or monthlv).

o Earning from work: List the gross income each person earned from work. This is not the same as take-homepay. Gross income is the amount earned before taxes and other deductions. Net income shouldONLY be reported for self-owned business, farm, or rental income.

o All other income.' List the amount each person got last month from welfare, child support, and alimony in thesecond column, List the amount each person got last month from pensions, ret i rement, and Social Securi ty inthe third column, List Al l Other Income sources in the fourth column. Al l Other Income includes Worker 'sCompensation, unemployment, strike benefits, Supplemental Security Income (SSI), Veteran's benefits (VAbenef i ts), disabi l i ty benef i ts, regular contr ibut ions from people who do not l ive in your household, and ANYOTHER INCOME.

o I f the person does not have any income, circ le "NO" in the last column "Circle i f NO income."Part 5: An adult household member must sign and date the form, and l ist a social securi ty number or check the box "I do

not have a social securi ty number."Part 6: Skip this part .Part 7: Answer this question if you choose to.

Letter to Parents5107 Page 2