Contact information and adult signature

“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.”

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.

Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?

If so, please enter your case number and press 'Yes'

If anyone in your household participates in the assistance programs listed below, your children are eligible for free school meals:

  • The Supplemental Nutrition Assistance Program (SNAP) or [insert State SNAP here]
  • Temporary Assistance for Needy Families (TANF) or [insert State TANF here]
  • The Food Distribution Program on Indian Reservations (FDPIR)

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

A. Child Income

$
.00

B. All Adult Household Members (including yourself)

If anyone in your household participates in the assistance programs listed below, your children are eligible for free school meals:

  • The Supplemental Nutrition Assistance Program (SNAP) or [insert State SNAP here]
  • Temporary Assistance for Needy Families (TANF) or [insert State TANF here]
  • The Food Distribution Program on Indian Reservations (FDPIR)
  • -Salary, wages, cash bonuses
  • -Net income from self-employment (farm or business)
  • -Strike benefits

If you are in the U.S. Military:

  • -Basic pay and cash bonuses (do NOT include combat pay, FSSA or privatized housing allowances)
  • -Allowances for off-base housing, food, and clothing
  • -Unemployment benefits
  • -Worker’s compensation
  • -Supplemental Security Income (SSI)
  • -Cash assistance from State or local government
  • -Alimony payments
  • -Child support payments
  • -Veteran’s benefits
  • -Social Security (including railroad retirement and black lung benefits)
  • -Private Pensions or disability
  • -Income from trusts or estates
  • -Annuities
  • -Investment income
  • -Earned interest
  • -Rental income
  • -Regular cash payments from outside household

Enter the total number of household members in the field “Total Household Members (Children and Adults).” This number MUST be equal to the number of household members listed in STEP 1 and STEP 3. If there are any members of your household that you have not listed on the application, go back and add them. It is very important to list all household members, as the size of your household determines your income cutoff for free and reduced price meals.

Provide the last four digits of your Social Security Number. The household’s primary wage earner or another adult household member must enter the last four digits of their Social Security Number in the space provided. You are eligible to apply for benefits even if you do not have a Social Security Number. If no adult household members have a Social Security Number, leave this space blank.

OPTIONAL Children's Racial and Ethnic Identities

Ethnicity

Race

Review and Guidelines