DGF School District

Dear Parent/Guardian:

Our school provides healthy meals each day. Breakfast costs $1.30; lunch costs: Elementary $2.70, Middle & High School $2.80 

Your children may qualify for free or reduced-price school meals. To apply, complete the enclosed Application for Educational Benefits following the instructions. A new application must be submitted each year. At public schools, your application also helps the school qualify for education funds and discounts.

State funds help to pay for reduced-price school meals, so all students who are approved for either free or reduced-price school meals will receive school meals at no charge. State funds also help to pay for breakfasts for kindergarten students, so all participating kindergarten students receive breakfasts at no charge.

Return your completed Application for Educational Benefits to:

Food Service, DGF Schools, PO Box 188, Dilworth MN 56529-0188

Who can get free school meals? Children in households participating in the Supplemental Nutrition Assistance Program (SNAP), Minnesota Family Investment Program (MFIP) or Food Distribution Program on Indian Reservations (FDPIR), and foster, homeless, migrant and runaway children can get free school meals without reporting household income. Alternatively, children can get free school meals if their household income is within the maximum income shown for their household size on the instructions.

To apply for free school meals, please complete the Application for Educational Benefits form.

COMMON QUESTIONS:

I get WIC or Medical Assistance. Can my children get free school meals? Children in households participating in WIC or Medical Assistance do not automatically qualify for free meals.  Children may be eligible for free or reduced-price school meals depending on other household financial information. Please fill out an application.  

Who should I include as household members? Include yourself and all other people living in the household, related or not (such as grandparents, other relatives, or friends).

May I apply if someone in my household is not a U.S. citizen? Yes. You or your children do not have to be U.S. citizens for your children to qualify for free or reduced-price school meals.

What if my income is not always the same? List the amount that you normally get. If you normally get overtime, include it, but not if you get overtime only sometimes. For seasonal work, write in the total annual income.

Will the income information or case number I give be checked? It may be. We may also ask you to send written proof.

How will the information be kept? Information you provide on the form, and your child’s approval for meal benefits, will be protected as private data. For more information see the back page of the Application for Educational Benefits.

If I don’t qualify now, may I apply later? Yes. Please complete an application at any time if your income goes down, your household size goes up, or you start getting SNAP, MFIP or FDPIR benefits.

Please provide the information requested about children’s racial identity and ethnicity, which helps to make sure we are fully serving our community. This information is not required for approval of school meal benefits.

If you have other questions or need help, call 218-477-6898.

Sincerely,


How to Complete the Application for Educational Benefits

Complete the Application for Educational Benefits form for school year 2019-20 if any of the following applies to your household:

Maximum Total Income

Household size

$ Per Year

$ Per Month

$ Twice Per Month

$ Per 2 Weeks

$ Per Week

1

23,107

1,926

963

889

445

2

31,284

2,607

1,304

1,204

602

3

39,461

3,289

1,645

1,518

759

4

47,638

3,970

1,985

1,833

917

5

55,815

4,652

2,326

2,147

1,074

6

63,992

5,333

2,667

2,462

1,231

7

72,169

6,015

3,008

2,776

1,388

8

80,346

6,696

3,348

3,091

1,546

Add for each additional person

8,177

682

341

315

158

Step 1: Children

List all infants and children in the household, their school and grade if applicable, and birthdate. Attach an additional page if needed to list all children. Check the box if a child is in foster care (a welfare agency or court has legal responsibility for the child).

Step 2: Case Number 

If any household member currently participates in SNAP, MFIP or FDPIR, write in the case number and then go to Step 4. If you do not participate in any of these programs, leave Step 2 blank and continue on to Step 3.

Step 3: Adult and Child Incomes / Last 4 Digits of Social Security Number

Step 4: Signature and Contact Information An adult household member must sign the form. If you do not want your information to be shared with Minnesota Health Care Programs, check the “Don’t share” box in Step 4.

Optional: Please provide the information on ethnicity and race that is requested on the second page of the form. This information is not required and does not affect approval for school meal benefits. The information helps to ensure we are meeting civil rights requirements and fully serving our community.

Minnesota Department of Education

2019-20 Application for Educational Benefits

Complete one application per household. Please use pen (not a pencil).

STEP 1:        List ALL Household Members who are infants, children, and students up to and including grade 12 (if more spaces are required for additional names, attach another sheet of paper).

Definition:  A Household Member is “Anyone living with you and shares income and expenses, even if not related.”  Children in Foster care are eligible for free meals. Read How to Complete the Application for Educational Benefits for more information.

Child’s First Name

MI

Child’s Last name

School

Grade

Birthdate

Foster Child (√)

STEP 2: Do Any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, MFIP or FDPIR? Medical assistance does not qualify.

        If YES >Enter SNAP, MFIP or FDPIR Case Number _____________________________  then go to STEP 4 (Do not complete STEP 3)        If NO > Go to STEP 3.

STEP 3: Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2)

Child Income

Weekly

Bi-weekly

2x Month

Monthly

$

  1. Child Income

Sometimes children in the household earn or receive income.  Please include the TOTAL income
received by all children listed in STEP 1.

  1. All Adult Household Members (including yourself). For each Household Member listed, if they do receive income, report total gross income only. If they do not receive income from any source, write ‘0’ or leave any fields blank. You are certifying (promising) that there is no income to report.


Not sure what income to include here? Flip the page and review “Sources of Income” for information.  “Sources of Income” will help you with the Child Income section and All Adult Household Members section.

Name of Adult Household Members

(First and Last)

List all Household members not listed in STEP 1 (including yourself) even if they do not receive income. Include children who are temporarily away at school or in college.

Na

Weekly

Bi-Weekly

2x Month

Monthly

Gross earnings from Work

Report income before deductions or taxes, for each source in whole dollars (no cents).

Na

Monthly

Yearly

Net income from
Self-Employment

Na

Weekly

Bi-Weekly

2x Month

Monthly

All Other Gross  Income such as SSI, Unemployment, Public Assistance, Child Support, and others on Page 2

$

$

$

$

$

$

$

$

$

$

$

$

  1. Last Four Digits of Social Security Number (SSN) of Primary Wage Earner or Other Adult Household Member XXX-XX-_____________   Check if no SSN: ☐  Total Household Members (Children and Adults) _________

STEP 4: Contact information and adult signature.  Mail or return completed form to: (School/District Information) ________________________________________________________________________________________

“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is give in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.”

All Total Income
(Include child and adult income)

Weekly

Bi-weekly

2X Month

Monthly

Annualize

Household Size

Categorical Eligibility

Free

Reduced

Denied

$

  I have checked this box if I do not want my information shared withFor school use only boarderDivider Line

Minnesota Health Care Programs as allowed by state law.          Do not fill out:  For School Use Only

        _________________________        Annual Income Conversion:  

Printed name of adult signing form        Weekly x 52

        Bi-Weekly x 26

                                Twice a Month x 24

Street Address (if available)        Apt#         City        Zip                Monthly x 12

   Selected for Verification – attach Verification Tracker

        _______________________________________                                

Signature of Household Adult        Daytime Phone        Determining Official’s Signature        Date        Confirming Official’s Signature        Date

INSTRUCTIONS: Sources of Income

Sources of Income for Children        Sources of Income for Adults

Sources of Child Income

Examples

NA

Earnings from Work

Public Assistance / Alimony

/ Child Support

All Other Income

  • Earnings from work
  • Social Security
  1. Disability Payments
  2. Survivor’s Benefits
  • Income from person outside the household
  • Income from any other source
  • A child has a regular full or part-time job where they earn a salary or wages
  • A child is blind or disabled and receives Social Security
  • A Parent is disabled, retired, or deceased, and their child receives Social Security benefits
  • A friend or extended family member regularly gives a child spending money
  • A child receives regular income from a private pension fund, annuity, or trust

  • Salary, wages, cash bonuses (before deductions or taxes)
  • Net income from self-employment (farm or business)
  • If you are in the U.S. Military:
  1. Basic pay and cash bonuses (do NOT include combat pay, FSSA or privatized housing allowances)
  2. Allowances for off-base housing, food and clothing
  • Cash Assistance from State or local government
  • Supplemental Security Income
  • Unemployment benefits
  • Worker’s compensation
  • Alimony payments
  • Child support payments
  • Veteran’s benefits
  • Strike benefits
  • Social Security
  • Disability benefits
  • Regular income from trusts or estates
  • Annuities
  • Investment income
  • Rental income
  • Regular cash payments from outside household

OPTIONAL: Children’s Racial and Ethnic Identities

We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children’s eligibility for free or reduced price meals.  

Ethnicity (check one):    Hispanic or Latino    Not Hispanic or Latino  

Race (check one or more):    American Indian or Alaskan Native    Asian    Black or African American    Native Hawaiian or Other Pacific Islander    White

The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.

At public school districts, each student’s school meal status also is recorded on a statewide computer system used to report student data to MDE as required by state law. MDE uses this information to: (1) Administer state and federal programs, (2) Calculate compensatory revenue for public schools, and (3) Judge the quality of the state’s educational program.

Nondiscrimination statement: In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, you have two options: 1. Complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at Filing a Program Discrimination Complaint as a USDA Customer, and at any USDA office; or, 2. Write a letter addressed to USDA; provide in the letter all of the information requested in the form. To request a copy of the complaint form, call 866-632-9992. Submit your completed form or letter to USDA by one of the following methods:

(1)   Mail:        U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW

Washington, D.C. 20250-9410;

(2)   Fax: 202-690-7442; or

(3)   Email: program.intake@usda.gov

This institution is an equal opportunity provider.