Instructions for School Officials Determining Eligibility For ......5/17 1 Instructions for School Officials Determining Eligibility For Free and Reduced Price School Meals/ Special

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Instructions for School Officials Determining Eligibility For Free and Reduced Price School Meals/ Special Milk Program

PUBLIC MEDIA RELEASE: Near the beginning of each school year, all Local Education Agencys (LEA) are required to notify the public that free and reduced price meals and free milk (if applicable) are available. It must be provided to the local news media, the unemployment office, and any major employers who are contemplating large layoffs in the attendance area of the school. The State Agency has written a public meda release for 2017-2018 that contains all of the required information (available on IowaCNP under Download Forms NSLP176). The State Agency no longer sends the Public Release to “The Link” for distribution.

INFORMATION LETTERS TO HOUSEHOLDS (PARENT LETTER): At the beginning of school, information letters must be distributed to the households of children attending the school. The information letter must be sent to households of all school children either before the beginning or very early in the school year (cannot be sent home at the end of the school year for the next year). The LEA cannot accept and process applications before July 1st (year-round schools may distribute the letters in June). The letters may be distributed by the postal service, e-mailed to the parent or guardian, or be included in an information packet provided to students. If the LEA uses a web-based system as one of their application processes, the letter to households must inform the household how to access the system in order to apply for benefits.

DIRECTLY CERTIFIED STUDENTS: Mid July the initial direct certification list will be available on the Iowa Education Portal. If you already have an A&A Account, you will not need to acquire a new account or lon in. If you do not have an A&A Account, you will need to complete a Direct Certificaiton/E-Lookup Access Request Form (on IowaCNP-NSLP002). Direct certification is a procedure to automatically qualify foster children and children from Food Assistance (FA) and Family Investment Program (FIP) households for free meals. New in 2017-2018, the Department of Education and the Department of Human Services were able to match on additional records so there will also be an “Other Free” and “Other-Reduced” category. Within ten days, after receiving the direct certification list, the LEA should send a notification letter to these households informing them that they will be receiving free or reduced price meal benefits, that no application is necessary, how to decline meal benefits, an opportunity to decline having their household information released to hawk-i and if the LEA waives any school fees a waiver statement should be added in the space provided (prototype waiver statement available on IowaCNP under Download Forms.) If the LEA does receive an application from a household that is directly certified, the application should be marked “directly certified” and dated. These applications should be kept separate from all other applications received by the LEA. The direct certification list will have a number “1” in one or more of the columns labeled Food Assistance, FIP, Foster Care, Other Free and Other Reduced. When notifying households that their children will receive reduced price meals due to them being identified as Othe Reduced on the direct certification list, they must be informed that their household income as reported to DHS was within the reduced price eligibility limits and that they should see the income guidelines which are in the Information Letter they received and if they feel they would qualify for free meal benefits that they should complete an application for free and reduced price meals.

HOUSEHOLD APPLICATIONS: LEAs must provide household applications to families applying for free or reduced price meals or free milk benefits, unless the household has been directly certified. Prior to printing the application, LEAs should add the URL at the top of the page if household’s have the opportunity to apply via a web-based application. Also, if the LEA waives any school fees, a waiver statement should be added to the application in the space provided. In addition, LEAS should insert your school/district mailing address in Step 4. A prototype waiver statement is available on IowaCNP in download forms. If the LEA uses paper applications, the Application for Free and Reduced Price Meals/Milk (front and back) and the How to Apply for Free and Reduced Price School Meals/Milk instructions should be printed and included with the Information Letter. An Optional Supplemental Worksheet may be included or LEAs can inform households that the worksheet is available if they need additional spaces for household members, are self-employed or if the household wishes to sign the waiver form. The LEA may make available and accept applications electronically or scan paper applications.

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HOUSEHOLDS ARE RESPONSIBLE FOR COMPLETING THEIR OWN APPLICATIONS: While schools are expected to provide support and assistance, the applicants themselves should complete as much of the application as they are able. We encourage parents to complete one application and provide copies of the same application to all Child Nutrition Programs in which their children participate. Child Nutrition Programs may share eligibility information among themselves. We encourage programs to develop cooperative relationships among other Child Nutrition Program operators or managers to maximize the number of eligible children receiving benefits.

EXTENSION OF CATEGORICAL ELIGIBILITY IN HOUSEHOLDS: If any person in the household currently receives Food Assistance or Family Investment Program (FIP) benefits as identified on the Application for Free and Reduced Price School Meals/Milk or under direct certification, free meal eligibility extends to anyone in the household who participates in any Child Nutrition Program. The same is true for households identified under Other Free and Other Reduced. Students who are identified as Foster Care on the direct certification list will receive free meal benefits; however the benefits do not extend to other students in the household. For additional information on extending eligibility see the document on IowaCNP titled “Extending Categorical Eligibility to Additional Children in a Household. The LEA approving the application is responsible to maintain documentation sufficient to demonstrate eligibility. Direct Certification lists and Applications must be kept for 3 years plus the current year.

YEAR LONG ELIGIBILITY: Households are NOT required to report changes in income, household size or eligibility for Food Assistance or FIP. Once properly approved for free or reduced price benefits, a household will remain eligible for the entire year plus the first 30 operating days of the following year. Households may apply or reapply at any time. If a household voluntarily reports changes and a change is reported that will increase benefits, the LEA must put that change into effect. However, if the change will decrease benefits (from free to reduced price) or terminate benefits (from free or reduced price to paid), the LEA must explain to the household that the change does not have to go into effect, but the household may request that the lower benefits go into effect. Even if benefits are decreased at the households request, the LEA must send a notice indicating the change in the household’s eligibility status.

CATEGORICAL ELIGIBILITY FOR CHILDREN ENROLLED IN HEAD START: Children enrolled in Head Start programs are automatically eligible for free meals and remain eligible for the entire year (Oct.- Sept.). Eligibility for free meals is granted ONLY to children enrolled in Head Start. Their siblings are NOT automatically granted free meal status and must qualify for benefits based on income, receipt of Food Assistance or FIP benefits or have migrant, homeless, or runaway status in school programs. Head Start children are included as members of their households for income-based determinations. Documentation of Head Start enrollment must be provided by the Head Start agency, which may include an approved application, a letter of enrollment, or a list of enrolled Head Start children.

ETHNIC AND RACIAL INFORMATION: Child Nutrition Programs must collect and maintain data regarding the ethnic and racial characteristics of the children who are receiving and denied benefits. Households may self-identify ethnic and racial information for children on the back of the applicaiton. Child Nutrition Programs must make a visual determination of the ethnic and racial characteristics for any person who has not self identified. Once this data is collected, the LEA should complete the Racial/Ethnic Form which is located on IowaCNP under Download Forms (NSLP190).

INCOMPLETE APPLICATIONS: Households that submit an incomplete application cannot be approved if required information is missing. The missing information must be obtained before an eligibility determination can be made. To get the required information, the LEA may return the application to the household or contact the child’s parent or guardian, either by phone or in writing, including e-mail. The determining official should document the details of the contact, and date and initial the entry. Households that provide pay stubs, but do not indicate the amount of income for each adult household member on the application are considered incomplete. Applications missing the signature of an adult household member must be returned to the household for a signature. An application missing the last four digits of the social security number can be obtained via a phone call or e-mail.

THE DETERMINING OFFICIAL REVIEW: The Determining Official will review Steps 1-4 of the application, as applicable and then complete the section identified as being “FOR ADMINISTRATIVE USE ONLY. “ Use the guidelines below to make decisions related to eligibility.

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FOSTER CHILD: The adult completing the application will mark the checkbox for a foster child in Step 1, if applicable. Foster children can be included as household members or reported on a separate application. If a foster child is included as a household member, the household must report any personal income received by the foster child on their household application. Foster payments received by the family from the placing agency are not considered income and do not need to be reported. When approved, the Determining Official will mark the “foster child” checkbox if the application was completed solely on behalf of the foster child. If the foster child was included as a Household Member, the Determining Official will mark the “Foster Child and Income” checkboxes. Complete the Eligibility Determination, sign and date the application.

HOMELESS/RUNAWAY CHILD: The LEA’s homeless liaison may complete an application on behalf of a homless or runaway student or provide a letter to the Determining Official stating that the student is homeless or a runaway. The letter or application must be signed by the liaison. An official from a homeless shelter may send a letter to the LEA identifying that the student(s) is/are residing at the shelter. Documentation to substantiate free meal eligibility must include the child’s name or list of names, effective date(s) and the signature of the local homless liaison or the director of the shelter or transitional housing project. This documentation is acceptable in lieu of a completed application. The homeless or runaway child remains eligible for free meal benfits for the entire school year plus 30 operating days into the new school year regardless of where he/she is living. Note; Categorical eligibility based on homless/runaway status does not extend to other children in the household.

MIGRANT CHILD: Migrant children are categorically eligible for free meal benefits. Migrant students should be identified by downloading the Migrant list off of the portal. If the student has been identified as migrant on the Direct Certification download, no further documentation is needed. Eligibility determination for migrant children must be made each year and eligibility is year long plus for the first 30 operating days of the new school year. Note: Categorical eligibility based on migrant status does not extend to other children in the household.

FOOD ASSISTANCE OR FAMILY INVESTMENT PROGRAM: The Determining Official will mark the Food Assistance/ FIP checkbox when a household completes Step 2 with a Food Assistance or FIP case number. NOTE: THE NUMBER ON THE EBT/DEBIT CARD OR FIP CARD IS NOT THE CASE NUMBER. The case number is 10 characters and is on the DHS Notice of Decision. Households completing the application based on participation in Food Assistance or FIP programs, but failing to provide a valid case number must be denied. Mark the check box “Incomplete”. A Food Assistance or FIP number for any household member qualifies all household members for free meal benefits if they participate in any Child Nutrition Programs.

INCOME: In the section identified as being “FOR ADMINISTRATIVE USE ONLY” the Determining Official will record the total amount of Household Income, frequency of income and Household Size when a household completes Step 3 – Report Income for ALL Household Members (be sure to add in the Total Child Income). Determining Officials are encouraged to use the current ICAVES tool to determine eligibility, available in the Download Forms section of IowaCNP.

For each Household Member listed, if they do receive income, they are to report total gross income for each source in whole dollars only. If they do not receive income from any source, they are to write ‘0.’ If a Household enters ‘0’ or leaves any fields blank, they are certifying that there is no income to report.

If household income is reported with only one frequency (such as all weekly or all monthly), compare the sum of the incomes to the Income Eligibility Guidelines for that frequency. Check the appropriate box and fill in the blank with the sum of the incomes and household size.

If a household reports income in more than one frequency (such as one income weekly and another monthly), convert all income to annual by using the conversion factors. DO NOT ROUND THE CONVERSIONS. Compare the sum of the annualized incomes to the Income Eligibility Guidelines for annual income. Check the “annually” box and fill in the blank with the sum of the annualized incomes and household size.

Check the appropriate box beside Application Approved (Income, Foster Care, FIP/Food Assistance, etc.).

If the household qualifies, check the appropriate box beside Eligibilitiy Determination, Free, Reduced, or Free Milk. If the household does not qualify, mark “Incomplete or Over Income Limits” beside Application Denied. Sign and date the application where it says “Determining Official”.

The Determining Official makes the initial eligibility determination and will sign and date the application.

EFFECTIVE DATE: The effective date is the date the Determining Official has made the eligibility determination.

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VERIFICATION: Verificaiton is confirmation of eligibility for free and reduced meals. Verification is only required when eligibility is determined through the application process, not through direct certification, including children documented as eligible migrant, runaway, homeless children; foster children found on the direct certification list; and children enrolled in Head Start. Each LEA must annually verify eligibility of children from a sample of household applications approved for free and reduced price benefits for that school year. The sample size must be based on the October 1 sample pool. The LEA must complete the verification activities no later than November 15 of each school year.

CONFIRMING OFFICIAL SIGNATURE LINE: The Confirming Official reviews all applications selected for the verification process prior to conducting any other verification activity and checks to ensure that the initial determination was accurate. The Determining Official and the Confirming Official cannot be the same person. If the initial determination was incorrect, the LEA should take one of the following actions:

If the status changes from reduced price to Free, based on the Confirmation Review, the LEA makes the increased benefits available immediately; notifies the household of the change in benefits; and verifies the application.

If the status changes from free to reduced price, based on the Confirmation Review, the LEA does not change the child’s status; and verifies the application. If the child’s free status is verified, the LEA does not notify the household. However, if the child’s status changes from free to either reduced price or paid, the household is sent a notice of adverse action.

If the status changes from free or reduced price to paid, based on the Confirmation Review, the LEA immediately sends the household a notice of adverse action; does not verify the application; selects another similar application for verification and follows the confirmation review procedures for the newly selected application.

As the Confirming Official checks each application, he/she should sign and date the application where it says “Confirming Official.” Once the confirming reviews are completed, the LEA will proceed with the verification process.

FOLLOW-UP OFFICIAL SIGNATURE LINE: There is a formal follow-up requirement for households that fail to respond to the initial request for verification. The Follow-up Official may be the same person as the Determining Official or the Confirming Official. The Follow-up Official must make at least one attempt to obtain the necessary documentation from the household. The attempt may be made through the mail, telephone, email or personal contact. The LEA must document any attempts and the results, if any. If the LEA is unable to verify the household's eligibility status after the follow-up attempt(s), the household's benefits must be terminated. The LEA may contract with a third party to assist with the required follow-up activity. Any third party is subject to the confidentiality requirements outlined in the current regulations. Upon completing the follow-up, the individual should sign and date the application where it says “Follow-up Signature.” For additional information, review the Verification section of the Eligibility Manual for School Meals (click here).

hawk-i/MEDICAID SECTION: Public LEAs are required and nonpublic LEAs are encouraged to release the names of students eligible for free and reduced price meals to the hawk-i program annually. The list shall include names of students whose parents/guardians have requested information on hawk-i. The parent/guardian, not any household adult, must sign the hawk-i/Medicaid information section if they do not want their children’s names released. Households completing an Iowa Application for Free and Reduced Price meals have the opportunity to sign that they don’t want their information released. Directly certified households should be given the opportunity to sign htat they don’t want their information relased on the notification letter.

LEAs have from August 31, 2017 until December 4, 2017 to submit names

All written references to hawk-i should be in italic font, lower case and bold;

The haw-i reporting form and Memorandum of Agreement (MOA) are posted in the Download Forms section of IowaCNP.

WAIVER STATEMENT: All households that are approved for free and reduced price meal benfits via an application or by direct certification must be given the opportunity to sign a waiver if the LEA offers fee waivers. A waiver signed by the parent/guardian must be on file to disclose free or reduced price eligibility information regarding individual households. A place holder for a fee waiver statement is on the back page of the application for free and reduced price meals. LEAS are responsible to meet all requirements for waivers whether the simple waiver statement provided on IowaCNP (NSLP224) is used or a waiver

https://www.educateiowa.gov/pk-12/nutrition-programs/school-nutrition/income-eligibility-and-verification

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statement developed by the LEA is used. LEAs that choose not to use this space for their fee waivers must leave the space blank and must develop a separate form if the LEA plans to waive school fees. Directly certified households should be given the opportunity to sign a fee waiver on the notification letter.

USDA ELIGIBILITY MANUAL FOR SCHOOL MEALS: USDA annually updates the Eligibilitiy Manual for School Meals. This guidance is an excellent resource and should be utilized fully when determining student’s eligibility status at the beginning of the school year as well as throughout the year. LEAs should use the July 29, 2016 manual until the 2017 version is released (click here).

ICAVES – IOWA CERTIFICATION AND VERIFICATION EXCEL SPREADSHEET: This is a tool designed to assist LEAs in eligibility determination based on income and household size and for determining the LEAs sample size during verification. ICAVES for 2017-2018 is in the Download Forms section of IowaCNP (NSLP111). If you have questions, call Deb Linderblood at the Bureau of Nutrition and Health Services at (515) 281-5663 or e-mail [email protected].

https://www.educateiowa.gov/pk-12/nutrition-programs/school-nutrition/income-eligibility-and-verificationmailto:[email protected]

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INFORMATION LETTER Frequently Asked Questions About Free And Reduced Price School Meals

Dear Parent/Guardian:

Children need healthy meals to learn. Union Community School District offers healthy meals every school day. Breakfast cost $l.65;

lunch costs $2.70 (elementary), $3.00 (middle school), and $3.05 (high school). Your children may qualify for free meals/milk or for

reduced price meals. Reduced price is $.30 for breakfast and $.40 for lunch. Return or mail the completed application to: Principal of

your child(ren) building – LPC Elementary, 515 Fillmore, La Porte City; DG Elementary, 411 Lincoln, Dysart; UMS 505 West Street,

Dysart; UHS, 200 Adams, La Porte City.

Below are some common questions and answers to help you with the application process.

1. WHO CAN GET FREE OR REDUCED PRICE MEALS?

All children in households receiving benefits from Food Assistance, the Family Investment Program (FIP) or a few

specific Medicaid programs are eligible for free or reduced price meals.

Foster children that are under the legal responsibility of a foster care agency or court are eligible for free meals.

Children participating in their school’s Head Start program are eligible for free meals.

Children who meet the definition of homeless, runaway, or migrant are eligible for free meals.

Children may receive free or reduced price meals if your household’s income is at or below the limits on the Federal Income Eligibility Guidelines below. (Requires submitting an Application for Free and Reduced Price Meals/Milk.)

FEDERAL INCOME ELIGIBILITY GUIDELINES for School Year 2018-2019

Household Size Yearly Monthly Twice per Month Every Two Weeks Weekly

1 22,459 1,872 936 864 432

2 30,451 2,538 1,269 1,172 586

3 38,443 3,204 1,602 1,479 740

4 46,435 3,870 1,935 1,786 893

5 54,427 4,536 2,268 2,094 1,047

6 62,419 5,202 2,601 2,401 1,201

7 70,411 5,868 2,934 2,709 1,355

8 78,403 6,534 3,267 3,016 1,508

Each additional person: 7,992 666 333 308 154

2. SHOULD I FILL OUT AN APPLICATION IF I RECEIVED A LETTER THIS SCHOOL YEAR SAYING MY CHILDREN ARE ALREADY APPROVED

FOR FREE OR REDUCED PRICE MEALS? No, but please read the letter carefully and follow the instructions. If any children in your household were missing from your notification, contact: District Office, 200 Adams, La Porte City, IA 50651 or 319-342-

2674/800-670-4686 or c_grote @union.k12.ia.us immediately as eligibility for free or reduced price meals is extended to all

school age children in a household. If you did not receive a letter from the school, but received a Free Lunch Notice from DHS,

submit this letter to your children’s school. You may add any students living in your household who are not listed on the letter.

Also, if someone in your household receives food assistance and you did not receive either of these letters, you may complete an

application listing the case number as this will qualify all school age children in your household for free meals. If you were

informed that your children will get reduced price meals automatically, see the income guidelines above and if you feel you would

qualify for free meal benefits, complete an application for free and reduced price meals.

3. WHAT IF WE HAVE FOSTER CHILDREN? Households with foster and non-foster children may choose to include the foster child as a household member, as this may help other children in the household qualify for benefits. If the foster family is not eligible for free

or reduced price meal benefits, that does not prevent a foster child from receiving free meal benefits.

4. HOW DO I KNOW IF MY CHILDREN QUALIFY AS HOMELESS, MIGRANT, OR RUNAWAY? Do the members of your household lack a permanent address? Are you staying together in a shelter, hotel, or other temporary housing arrangement? Does your family

relocate on a seasonal basis? Are any children living with you who have chosen to leave their prior family or household? If you

believe children in your household meet these descriptions and haven’t been told your children will get free meals, please contact:

Wayne Slack, Union Community School District’s homeless liaison, or migrant coordinator at 319-342-2697/800-670-4686.

5. DO I NEED TO FILL OUT AN APPLICATION FOR EACH CHILD? No. Use one Free and Reduced Price School Meals Application for

all students in your household. We cannot approve an application unless complete eligibility information is submitted, so be sure

to complete all required information.

6. MY CHILD’S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT A NEW ONE? Yes. Your child’s application is only good for that school year and for the first few days of this school year, through October 5, 2018.

You must send in a new application unless the school told you that your child is eligible for the new school year. When the carry-

over period ends, unless you are notified that your children will receive free meals or you submit an application that is approved,

the children must pay full price for school meals. The school is not required to send a reminder or a notice of expired eligibility.

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7. I GET WIC. CAN MY CHILDREN GET FREE MEALS? Children in households participating in WIC may be eligible for free or

reduced price meals. Please send in an application.

8. MAY I APPLY IF SOMEONE IN MY HOUSEHOLD IS NOT A U.S. CITIZEN? Yes. You, your children, or other household members do

not have to be U.S. citizens to apply for free or reduced price meals.

9. WILL THE INFORMATION I GIVE BE CHECKED? Yes. We may also ask you to send written proof of the household income

you report. You are not required to provide proof with your application.

10. IF I DON’T QUALIFY NOW, MAY I APPLY LATER? Yes, you may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free or reduced price meals if the household income

drops below the income limit, if your household size goes up, or if you start getting Food Assistance, FIP or other benefits.

11. WHAT IF I DISAGREE WITH THE SCHOOL’S DECISION ABOUT MY APPLICATION? You should talk to school officials. You also may

ask for a hearing by calling or writing to: Supt Travis Fleshner, 200 Adams, La Porte City, IA 50651 or 319-342-2674/800-670-

4686 or t_fleshner @union.k12.ia.us

12. WHAT IF MY INCOME IS NOT ALWAYS THE SAME? List the amount that you normally receive. For example, if you normally make $1000 each month, but you missed some work last month and only made $900, put down that you made $1000 per month. If you

normally get overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours

or wages reduced, use your current income.

13. WHAT IF SOME HOUSEHOLD MEMBERS HAVE NO INCOME TO REPORT? Household members may not receive some types of income we ask you to report on the application, or may not receive income at all. Whenever this happens please write a 0 in the

field. However, if any income fields are left empty or blank, those will also be counted as zeroes. Please be careful when leaving

income fields blank, as we will assume you meant to do so.

14. WE ARE IN THE MILITARY. DO WE REPORT OUR INCOME DIFFERENTLY? Your basic pay and cash bonuses must be reported as income. If you get any cash value allowances for off-base housing, food, or clothing, or receive Family Subsistence Supplemental

Allowance payments, it must also be included as income. However if your housing is part of the Military Housing Privatization

Initiative, do not include your housing allowance as income. There are currently no active Military Housing Projects in Iowa as

found on Active Military Housing Projects. Any additional combat pay resulting from deployment is also excluded from income.

15. DO I NEED TO PROVIDE MY SOCIAL SECURITY NUMBER? Only the last four digits of the Social Security Number of the household’s

primary wage earner or another adult household member (or an indication of “none”) is needed.

16. WHAT IF THERE ISN’T ENOUGH SPACE ON THE APPLICATION FOR MY FAMILY? List any additional household members on a Supplemental Worksheet, and attach it to your application. Contact Principal’s Office at the building where your child(ren)

attend(s) to receive a Supplemental Worksheet.

17. WHO CAN GET FREE MILK? If your school participates in the Special Milk Program for half day kindergarteners, your kindergarten child may be eligible for free milk. Children who buy extra milk with a meal or if they eat breakfast or lunch and have an afternoon

milk break, they are not eligible to receive free milk.

18. MY FAMILY NEEDS MORE HELP. ARE THERE OTHER PROGRAMS WE MIGHT APPLY FOR? To find out how to apply for Food Assistance or other assistance benefits, contact your local assistance office or call 1-877-347-5678. Your children may be eligible

for hawk-i (children’s health insurance) or a waiver of school fees. Read the information on the back of the Application for hawk-i

information. A school waiver form is available from your school.

19. CAN CHILDREN WITH DISABILITIES GET FOOD SUBSTITUTIONS? If a child has a disability, as determined by a licensed medical professional, and the disability prevents the child from eating the regular school meal, the school will make substitutions

prescribed by the licensed medical professional. If a substitution is needed, there will be no extra charge for the meal. Please

note, however, that the school is not required to make a substitution for a food allergy, unless it meets the definition of disability.

Please call the school for further information.

If you have other questions or need help, call District Office at 319-342-2674 / 800-670-4686.

Sincerely,

Travis Fleshner, Superintendent

http://www.acq.osd.mil/housing/mhpi.htm

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How to Apply for School Meal Benefits ǀ Application Instructions

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HOW TO APPLY FOR FREE AND REDUCED PRICE SCHOOL MEALS/MILK

Please use these instructions to help you fill out the application for free or reduced price school meals/milk. You

only need to submit one application per household, even if your children attend more than one school in Union

Community School District . Please follow these instructions in order. Each step of the instructions is the same

as the steps on your application. The application must be filled out completely to certify your children for free or

reduced price school meals. Completed applications should be mailed or returned to Principal of your

child(ren) building – LPC Elementary, 515 Fillmore, La Porte City; DG Elementary 411 Lincoln, Dysart;

UMS , 505 West, Dysart; UHS, 200 Adams, La Porte City. If at any time you are not sure what to do next,

please contact your child(ren)’s attendance center; or Carol Grote, District Office, 200 Adams, La Porte

City or 319-342-2674 / 800-670-4686 or [email protected]

PLEASE USE A PEN (NOT A PENCIL) WHEN FILLING OUT THE APPLICATION AND DO YOUR BEST TO PRINT CLEARLY.

Tell us how many infants, children, and school students live in your household. They do NOT have to be related

to you to be a part of your household.

A) List each child’s name and date of birth. Print each child’s first name, middle initial, last name and date of

birth (optional). Use one line of the application for each child. If there are more children present than lines on

the application, attach a Supplemental Worksheet, which can be obtained from the school, with all required

information for the additional children.

B) Is the child a student? Mark ‘Yes’ or ‘No’ under the column titled “student” to tell us which children attend

Union Community School District. If you marked ‘Yes’ write where the child attends school and 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”.

Foster children who live with you may count as members of your household and should be listed on your

application. If you are applying for both foster and non-foster children, go to step 3.

D) Are any children homeless, migrant, or runaway? If you believe any child listed in this section may meet

this description, mark the “Homeless, Migrant, Runaway” box next to the child’s name and complete all

steps of the application.

STEP 1: LIST ALL HOUSEHOLD MEMBERS WHO ARE INFANTS, CHILDREN, AND STUDENTS UP TO AND INCLUDING GRADE 12.

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 foster arrangement, or qualify as homeless, migrant, or runaway youth;

Students attending Union Community School District regardless of age.

STEP 2: DO ANY HOUSEHOLD MEMBERS CURRENTLY PARTICIPATE IN FOOD ASSISTANCE, FIP, 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 Food Assistance Program (FA)

The Family Investment Program (FIP)

The Food Distribution Program on Indian Reservations (FDPIR)

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How to Apply for School Meal Benefits ǀ Application Instructions

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A) IF NO ONE IN YOUR HOUSEHOLD PARTICIPATES IN ANY OF THE ABOVE LISTED PROGRAMS:

Circle ‘NO’ and go to STEP 3. (Leave the rest of STEP 2 blank)

B) IF ANYONE IN YOUR HOUSEHOLD PARTICIPATES IN ANY OF THE ABOVE LISTED PROGRAMS:

Circle ‘YES’ and provide a case number for FA, FIP, or FDPIR. You only need to write one case

number. If you participate in one of these programs and do not know your case number, it is located on

your Notice of Decision. You must provide a case number on your application if you circled “YES”.

Go to STEP 4.

A) Report all income earned or received by children. Refer to the table below titled “Sources of Income for Children” and report the combined gross income for ALL children listed in Step 1 in your household in the

box marked “Total Child Income.” Only count foster children’s income if you are applying for them with the

rest of your household (income from a part-time job or from any funds provided to the child for the child’s

personal use). It is optional for the household to list foster children living with them as part of the household

on an application for non-foster children.

Table 1. Sources of Income for Children

Sources of Child Income Example(s) Earnings from work A child has a regular full or part-time job where they earn a

salary or wages. (Infrequent earnings, such as income from occasional babysitting or lawn mowing, are not counted as income.)

Social Security o Disability Payments o Survivor’s Benefits

A child is blind or disabled and receives Social Security benefits.

A parent is disabled, retired, or deceased, and their child receives social security benefits.

Income from person outside the household A friend or extended family member regularly gives a child spending money.

Income from any other source A child receives regular income from a private pension fund, annuity, or trust.

STEP 3: REPORT INCOME FOR ALL HOUSEHOLD MEMBERS

Report all amounts in GROSS INCOME ONLY. Report all income in whole dollars. Do not include cents.

Gross income is the total income received before taxes.

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 have known or available information 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.

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. Use the chart below to determine if your household has child income to report.

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FOR EACH ADULT HOUSEHOLD MEMBER: B) List Adult Household member’s name. Print the name of each household member in the boxes marked

“Name of Adult Household Members (First and Last).” Do not list any household members you listed in STEP 1.

C) Report earnings from work. Refer to the chart below titled “Sources of Income for Adults” and report 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 self-employed business or farm owner, you will report your net income. If

you need assistance with this, ask your children’s school for the Supplemental Worksheet which has self-

employment calculations.

D) Report income from public assistance/child support/alimony. Refer to the chart below titled “Sources of

Income for Adults” and report all income that applies in the “Public Assistance/Child Support/Alimony” field

on the application. Do not report the value of any cash value 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.

E) Report income from pensions/retirement/all other income. Refer to Table 2 below titled “Sources of Income for Adults” and report all income that applies in the “Pensions/Retirement/All Other Income” field on

the application.

Table 2. Sources of Income for Adults

Earnings from Work Public Assistance/ Alimony/Child Support

Pensions/Retirement/All Other Income

Salary, wages, cash bonuses

Net income from self-

employment (farm or business)

If you are in the U.S. Military:

Basic pay and cash bonuses (do NOT include combat pay, FSSA or privatized housing allowances)

Allowances for off-base housing, food and clothing

Unemployment benefits

Worker’s compensation

Supplemental Security Income (SSI)

Cash assistance from State or local government

Alimony payments

Child support payments

Veteran’s benefits

Strike benefits

Social Security (including railroad retirement and black lung benefits)

Private Pensions or disability benefits

Regular Income from trusts or estates

Annuities

Investment Income

Earned interest

Rental income

Regular cash payments from

What if I am self-employed?

If you are self-employed, report income from work as a net amount. This is calculated by subtracting the

total operating expenses of your business from its gross receipts and revenue. Ask your school for a

Supplemental Worksheet to assist you in determining your monthly gross annual income before

deductions.

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 not related and even if they do not receive

income of their own.

Do not include:

People who live with you but are not supported by your household’s income AND do not contribute

income to your household.

Children and students already listed in Step 1.

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F) Report 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.

G) 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 SSN.”

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 privacy and civil rights statements on

the back of the application.

A) Provide your contact information. Write your current address in the fields provided if this information is

available. If you have no permanent address, this does not make your children ineligible for free or

reduced price school meals. 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 and write today’s date. Print the name of the adult signing the application and

that person signs in the box. “Signature of adult completing the form.”

C) Mail or return completed form to: Your child(ren)’s building or Union Community School District, 200

Adams, La Porte City, IA 50651

D) 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. If you do not select race or ethnicity, one will be selected for

you based on visual observation.

E) Decline having your information released to hawk-i. If you do not want your household information shared

with hawk-i, print, sign and date in the box provided.

F) Obtaining translated applications. If you need a translated application with instructions, they can be found in

49 languages at: https://www.fns.usda.gov/school-meals/translated-applications.

outside household

STEP 4: CONTACT INFORMATION AND ADULT SIGNATURE

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WAIVER STATEMENT If your child(ren) qualifies for free or reduced price meals, you may also be eligible for other benefits. If you sign this waiver, your child(ren) will be considered for a full or partial waiver of school fees. I understand that I will be releasing information that will show that I applied for free and reduced price school meals for my child(ren). I give up my rights to confidentiality for waiver of school fees ONLY. I certify that I am the parent/guardian of the child(ren) for whom application is being made. YOU DO NOT HAVE TO COMPLETE THIS WAIVER TO GET FREE OR REDUCED PRICE SCHOOL MEALS.

Signature of Parent/guardian __________________________________________Date _________________

Schools-Part 1-Instructions for Officials on Approving the ApplicationsSchools-Part 2-Information LetterSchools-Part 3-How To Apply For Free and Reduced Price School MealsSchools-Part 5-Waiver Statement