Date Withdrew__________                                                                Attachment  Va        F ____R _____D_____

                                                                                                                

2018-2019 Application for Free and Reduced Price School Meals/Milk

To apply for free and reduced price meals for your children, read the instructions on the back, complete only one form for your household, sign your name and return it to the address listed below. Call (phone number), if you need help.  Additional names may be listed on a separate paper.

Return Completed Applications to:        Cathedral @ Pompei

923 north McBride Street

Syracuse, New York 13208

   

1. List all children in your household who attend school:

Student Name

School

Grade/Teacher

Foster Child

Homeless Migrant, Runaway


2.  SNAP/TANF/FDPIR Benefits:

If anyone in your household receives either SNAP, TANF or FDPIR benefits, list their name and CASE # here. Skip to Part 4, and sign the application.

Name: ______________________________________   CASE #: __________________________________


3. Report all income for ALL Household Members (Skip this step if you answered ‘yes’ to step 2)

All Household Members (including yourself and all children that have income).

List all Household members not listed in Step 1 (including yourself) even if they do not receive income.  For each Household Member listed, if they do receive income, report total income for each source in whole dollars only.  If they do not receive income from any other source, write ‘0’.  If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.

Name of household member

Earnings from work

before deductions

Amount / How Often

Child Support, Alimony

Amount / How Often

Pensions, Retirement

Payments

Amount / How Often

Other Income, Social Security

Amount / How Often

No Income

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

$ ________  / ________

Total Household Members (Children and Adults)        

                                *Last Four Digits of Social Security Number:  XXX-XX- __   __   __   __    

*When completing section 3, an adult household member must provide the last four digits of their Social Security Number (SS#), or mark the “I do not have a SS# box” before the application can be approved.


4.   Signature:  An adult household member must sign this application before it can be approved.

I certify (promise) that all the information on this application is true and that all income is reported.  I understand that the information is being given so the school will get federal funds; the school officials may verify the information and if I purposely give false information, I may be prosecuted under applicable State and federal laws, and my children may lose meal benefits.

Signature: ___________________________________________________   Date: ___________________  

Email Address: ________________________________________________

Home Phone: _____________________ Work Phone: _________________________ Home Address:____________________________________________


5. Ethnicity and Race are optional; responding to this section does not affect your children’s eligibility for free or reduced price meals.

Ethnicity:  Hispanic or Latino        Not Hispanic or Latino

Race: American Indian or Alaskan Native        Asian        Black or African American        Native Hawaiian or Other Pacific Island    White


APPLICATION INSTRUCTIONS

To apply for free and reduced price meals, complete only one application for your household using the instructions below. Sign the application and return the application to _____________________.  

If you have a foster child in your household, you may include them on your application. A separate application is not needed. Call the school if you need help:  ____________________. Ensure that all information is provided. Failure to do so may result in denial of benefits for your child or unnecessary delay in approving your application.

PART 1          ALL HOUSEHOLDS MUST COMPLETE STUDENT INFORMATION.  DO NOT FILL OUT MORE THAN ONE APPLICATION FOR YOUR HOUSEHOLD.

  1. Print the names of the children, including foster children, for whom you are applying on one application.
  2. List their grade and school.
  3. Check the box to indicate a foster child living in your household, or if you believe any child meets the description for homeless,  

       migrant, runaway (a school staff will confirm this eligibility).

PART 2        HOUSEHOLDS GETTING SNAP, TANF OR FDPIR SHOULD COMPLETE PART 2 AND SIGN PART 4.

  1.  List a current SNAP, TANF or FDPIR (Food Distribution Program on Indian Reservations) case number of anyone living in your household.

       The case number is provided on your benefit letter.

  1.  An adult household member must sign the application in PART 4.  SKIP PART 3.  Do not list names of household members or income if you list a

       SNAP case number, TANF or FDPIR number.

PART 3           ALL OTHER HOUSEHOLDS MUST COMPLETE THESE PARTS AND ALL OF PART 4.

  1. Write the names of everyone in your household, whether or not they get income.  Include yourself, the children you are applying for, all other children,    your spouse, grandparents, and other related and unrelated people in your household.  Use another piece of paper if you need more space.
  2. Write the amount of current income each household member receives, before taxes or anything else is taken out, and indicate where it came from, such as earnings, welfare, pensions and other income.  If the current income was more or less than usual, write that person’s usual income. Specify how often this income amount is received: weekly, every other week (bi-weekly), 2 x per month, monthly.  If no income, check the box. The value of any child care provided or arranged, or any amount received as payment for such child care or reimbursement for costs incurred for such care under the Child Care and Development Block Grant, TANF and At Risk Child Care Programs should not be considered as income for this program.
  3. Enter the total number of household members in the box provided. This number should include all adults and children in the household and should reflect the members listed in PART 1 and PART 3.
  4. The application must include the last four digits only of the social security number of the adult who signs PART 4 if Part 3 is completed.  If the adult does not have a social security number, check the box.  If you listed a SNAP, TANF or FDPIR number, a social security number is not needed.
  5. An adult household member must sign the application in PART 4.  

OTHER BENEFITS:  Your child may be eligible for benefits such as Medicaid or Children’s Health Insurance Program (CHIP).  To determine if your child is eligible, program officials need information from your free and reduced price meal application.  Your written consent is required before any information may be released.  Please refer to the attached parent Disclosure Letter and Consent Statement for information about other benefits.

USE OF INFORMATION STATEMENT

Use of Information Statement: 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 submit all needed information, 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 primary wage earner or other adult household member who signs the application. 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.

DISCRIMINATION COMPLAINTS

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, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and 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:

 

(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

 

This institution is an equal opportunity provider.