2018-2019 Iowa Application for Free and Reduced Price School Meals/Milk
Complete one application per household. This application cannot be approved unless complete eligibility information is submitted. If you would like to fill out a paper application instead of the online application please come in to Superintendents office to pick a paper copy up.
STEP 1: List ALL Household Members who are infants, children, and students up to and including grade 12
Definition of Household Member: “Anyone who is living with you and shares income and expenses, even if not related.”
Children in Foster care and children who meet the definition of Homeless, Migrant or Runaway are eligible for free meals. Read How to Apply for Free and Reduced Price School Meals for more information.
(A) Child’s First Name, MI,
Your answer
Child’s Last Name
Your answer
Is this child a student at Osage Community School District?
Child’s First Name, MI,
Your answer
Child’s Last Name
Your answer
Is this child a student at Osage Community School District?
Child’s First Name, MI,
Your answer
Child’s Last Name
Your answer
Is this child a student at Osage Community School District?
Child’s First Name, MI,
Your answer
Child’s Last Name
Your answer
Is this child a student at Osage Community School District?
Child’s First Name, MI,
Your answer
Child’s Last Name
Your answer
Is this child a student at Osage Community School District?
Child’s First Name, MI,
Your answer
Child’s Last Name
Your answer
Is this child a student at Osage Community School District?
Child’s First Name, MI,
Your answer
Child’s Last Name
Your answer
Is this child a student at Osage Community School District?
(B) Please list the names of the children who are Foster Care. If none please go on to next question.
Your answer
(C) Please list the names of the children who are Homeless or runaway. If none please go on to Step 2
Your answer
STEP 2: Current participation in assistance programs
Programs: Food Assistance, FIP, or FDPIR
(A) Do any Household Members (including you) currently participate in one or more of the above listed assistance programs?
(B) If No, complete STEP 3. If you answered Yes, write your 10 digit case number case number here then go to STEP 4 (Do not complete STEP 3). Write only one case number in this space. Medicaid, Title XIX & EBT card numbers are not acceptable
Your answer
Name of Household Member with Case Number:
Your answer
STEP 3 Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2)
Child Income: Sometimes children in the household earn income.
(A) Please list all income earned by all children listed in Step 1.
Your answer
How Often?
All Adult Household Members (including yourself)
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 gross income for each source in whole dollars only. If they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report. Applications with blank income fields will be processed as complete..
(B) Name of Adult Household Members (First and Last)
Your answer
(C) Earnings from Work
Your answer
How often
(D) Does this adult receive Public Assistance/Child Support/Allimony?
If yes how much?
Your answer
if yes how often?
Name of Adult Household Members (First and Last)
Your answer
Earnings from work
Your answer
How often?
Does this adult receive Public Assistance/Child Support/Allimony?
If Yes how much
Your answer
If yes, how often?
Name of Adult Household Members (First and Last)
Your answer
Earnings from work
Your answer
If yes, how often?
Does this adult receive Public Assistance/Child Support/Allimony?
If yes how much
Your answer
If yes, how often?
Name of Adult Household Members (First and Last)
Your answer
Earnings from work
Your answer
How Often?
Does this adult receive Public Assistance/Child Support/Allimony?
If yes how much
Your answer
If yes, how often
(E) Please put all other income you receive a month.
Your answer
How often do you receive other income?
(F) Please indicate below total number of individuals in household (including children and adults) *
(G) Do you have a Social Security Number? Only complete if applying based on income. *
(G) Last Four Digits of Social Security Number (SSN) (ONLY LAST FOUR DIGITS) of Primary Wage Earner or Other Adult Household Member ? *
Your answer
STEP 4 Contact Information and Adult Signature
(A) Name of person filling out application *
Your answer
Street Address
Your answer
Apartment number if any
Your answer
City
Your answer
State
Your answer
Zip
Your answer
By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.
“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.” *
Your answer
(B) Today's Date *
MM
/
DD
/
YYYY
(C) 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. If you do not select race or ethnicity, one will be selected for you based on visual observation.
Ethnicity: (check one)
Race Check one or more
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
Your answer
Low-Cost Health Insurance for Children
If your children do not have health insurance, many families getting free or reduced price meals can also get free or low-cost health insurance for their children. The law requires public schools to share your free and reduced price meal eligibility information with Medicaid & hawk-i, the State’s medical insurance program for children. Private schools, RCCIs and childcare organizations may choose to share this information. Specifically, we will give them your child’s name, your name & address. Medicaid & hawk-i can only use the information to identify children who may be eligible for free or low-cost health insurance and contact you. They are not allowed to use the information from your free and reduced meal application for any other purpose or to share it with any other entity or program. You are not required to allow us to share this information, it will not affect your child’s eligibility for free or reduced price meals. If you do NOT want your information shared with Medicaid or hawk-i, you must tell us by completing the information below. If you want further information, you may call hawk-i at 1-800-257-8563. Also, if you are already receiving Medicaid or hawk-i, please sign below. This will avoid another contact. My
(D) My signature below indicates I DO NOT want school officials to share information from my free and reduced price meal application with Medicaid or hawk-i.
Your answer
Translated applications are available in 49 languages at:
After you submit for all your children. Please Close Window / Tab and go on to the next step in the registration process
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