Free & Reduced Price School Meals Family Application-complete one application per household
Part 1: Chidren in School
List names of all children, including foster children, inschool. If all children listed are foster, skip to Part 4 to sign the form. (First, Middle Intitial, Last Name) Check box below if a foster child. Name of School Child Attends Grade
Part 2: SNAP, TANF or FDPIR Benefits
Enter MASTER CASE NUMBER if household qualifies for SNAP, TANF or FDPIR:
(Social Security numbers, Medicaid numbers and EBT number are not accepted.) Skip to Part 4    
Part 3: Total household Gross Income - You must tell us how much and how often.
1. Household Members
List everyone in the household, current income each person earns in whole dollars (no cents) & how often. Entering “0” or leaving the income field blank certifies no income to report. A foster child’s personal use income must be listed.
2. Gross Income and How Often it was Received
Earnings from Work before deductions Public Assistance, Child Support, Alimony Pensions, Retirement and All Other Income
  Income   How often   Income How often  Income  How often 
Total Number of Household Members:
(Children and Adults
  Last four digits of Social security Number (SSN) of the
adult signing this form: XXX-XX-
Adult Signature and Contact Information – An adult household member must sign the application.
An adult household member must sign the application. If Part 3 is completed, the adult signing the form must list the last four digits of their Social Security Number or mark the “I do not have a Social Security Number” box.  (See Use of Information Statement on page 2)  I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits and I may be prosecuted.
Name:   Your initials here: Date:
Address: Zip: Phone Number:
Part 5: Children's Ethnic and Racial Identities (Optional)
Mark one Ethnic Identity:  --and-- Mark one or more Racial Identities:
Do Not fill Out This Part. For School Use Only.
Annual Income Conversion: Weekly X 52; Every 2 Weeks X 26; Twice a Month X 24; Monthly X 12
Total Houshold Size__________________ Free           __
Total Income $__________________per
__Year __Month __2 X Mo. __Every 2 Wks __Week
Reduced   __ Date Withdrawn
from School: _________________
Categorically Eligible: SNAP/TANF/FDPIR __
Foster Child __
Denied       __    Reason for Denial:
Income too high __ Incomplete App. __
Signature of Determining Official _______________________________________________________________________ Date Approved: __________________________
Signature of Confirming Official (Verification only) ________________________________________________________ Date Approved: __________________________