Free & Reduced Price School Meals Family Application – complete one application per household Attachment C: 2024-25
Return Completed Application to: BLOOMFIELD COMMUNITY SCHOOLS, PO BOX 308, BLOOMFIELD, NE. 68718 Part 1: Children in School | |||||||||
List names of all children in school (First, Middle Initial, Last). If all children listed are foster, skip to Part 4 to sign the form. If some of the children are foster or are homeless, migrant or runaway children, complete all steps of the application. | Grade | Name of School Child Attends | Check all that apply: Homeless, Foster Migrant, Child Runaway | ||||||
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Part 2: Assistance Programs – SNAP, TANF or FDPIR Benefits | |||||||||
Enter MASTER CASE NUMBER if household qualifies for SNAP, TANF or FDPIR: (Social Security numbers, Medicaid numbers and EBT numbers 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 (before taxes) 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 – XXX – __ __ __ __ Check if no SSN ❑ | ||||||||
Part 4: Adult Signature and Contact Information – An adult household member must sign the application. | |||||||||
“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given 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.” Sign here: Print name: Date: | |||||||||
Street Address (if available): Zip: Daytime Phone: | |||||||||
Part 5: Children’s Ethnic and Racial Identities – Optional | |||||||||
Check one Ethnic Identity: – and – Check one or more Racial Identities: ❑Hispanic or Latino ❑Asian ❑Black or African American ❑Native Hawaiian or ❑Not Hispanic or Latino ❑White ❑American Indian or Alaskan Native other Pacific Islander | |||||||||
Do Not Fill Out the Section Below - For School Use Only | |||||||||
Annual Income Conversion: Weekly X 52; Every 2 weeks X 26; Twice a month X 24; Monthly X 12
Total Household Size:_______________________ Total Income:______________________________per ❑Year ❑Month ❑2 X Mo ❑Every 2 Wks ❑Week | ❑Free ❑Reduced ❑Denied ❑Income ❑Income Reason for denial: ❑Income too high ❑Categorically eligible: ❑SNAP/TANF/FDPIR ❑Incomplete application ❑Foster Child ❑Homeless/Migrant/Runaway: (Official Documentation Required at School) |
Signature of Determining Official: Date Approved: | |
FOR THE VERIFICATION PROCESS ONLY: Date Withdrawn Signature of Confirming Official From School: : Date Confirmed: Signature of Verifying Official: Date Verified: | |
NE Department of Education – Nutrition Services - National School Lunch Program Page 1 of 2
Free & Reduced Price School Meals Family Application – complete one application per household Attachment C: 2024-25
Your children may
FEDERAL INCOME CHART
for School Year 2024-25 | |||||
Household size | Yearly | Monthly | Twice per Month | Every Two Weeks | Weekly |
1 | 27,861 | 2,322 | 1,161 | 1,072 | 536 |
2 | 37,814 | 3,152 | 1,576 | 1,455 | 728 |
3 | 47,767 | 3,981 | 1,991 | 1,838 | 919 |
4 | 57,720 | 4,810 | 2,405 | 2,220 | 1,110 |
5 | 67,673 | 5,640 | 2,820 | 2,603 | 1,302 |
6 | 77,626 | 6,469 | 3,235 | 2,986 | 1,493 |
7 | 87,579 | 7,299 | 3,650 | 3,369 | 1,685 |
8 | 97,532 | 8,128 | 4,064 | 3,752 | 1,876 |
Each additional person: | 9,953 | 830 | 415 | 383 | 192 |
qualify for free or
reduced price
meals if your
household income
falls at or below the
limits on this chart.
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 are 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.
Non-Discrimination Statement: This explains what to do if you believe you have been treated unfairly.
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.
Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.
To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online
at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28- 17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted 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: (833) 256-1665 or (202) 690-7442; or
(3) Email: program.intake@usda.gov
This institution is an equal opportunity provider.
NE Department of Education – Nutrition Services - National School Lunch Program Page 2 of 2