Form - 2024-25 Application for Free and Reduced-Price School Meals

District

School

PART A: STUDENT INFORMATION – Complete for each student Pre-K through 12th Grade

Child 1: First Name

Child 1: Middle Initial

Child 1: Last Name

Is child 1 a student? Yes No

Child 1: School

Child 1: Grade Level

Child 1: Foster Child Yes No

Child 1: Homeless, Migrant, Runaway Yes No

Child 2: First Name

Child 2: Middle Initial

Child 2: Last Name

Child 2: Student Yes No

Child 2: School

Child 2: Grade

Child 2: Foster Child Yes No

Child 2: Homeless, Migrant, Runaway Yes No

Child 3: First Name

Child 3: Middle Initial

Child 3: Last Name

Child 3: Student Yes No

Child 3: School

Child 3: Grade

Child 3: Foster Child Yes No

Child 3: Homeless, Migrant, Runaway Yes No

Child 4: First Name

Child 4: Middle Initial

Child 4: Last Name

Child 4: Student Yes No

Child 4: School

Child 4: Grade Level

Child 4: Foster Child Yes No

Child 4: Homeless, Migrant, Runaway Yes No

Child 5: First Name

Child 5: Middle Initial

Child 5: Last Name

Child 5: Student Yes No

Child 5: School

Child 5: Grade Level

Child 5: Foster Child Yes No

Child 5: Homeless, Migrant, Runaway Yes No

PART B: BENEFITS RECEIVED - If any member of your household receives Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), or FDPIR, provide the name and case number for the person who receives benefits. Bridge Card Numbers and Medicaid Numbers are NOT ACCEPTABLE case numbers.

Name

Case number

PART C: HOUSEHOLD SIZE - Enter the total number of individuals living in your household, including all adults and children.

PART D: TOTAL MONTHLY HOUSEHOLD INCOME – Report income for all members of household excluding Foster Children. If you have reported a case number above, you do not need to fill in this section. Move on to PART E.

Gross Monthly Earnings: Wages, Salary, Commissions

Monthly Welfare Payments, Child Support, Alimony

Monthly Payments from Pensions, Retirement, Social Security

Monthly Dividends or Interest on Savings

Monthly Worker’s Compensation, Unemployment, Strike Benefits

Other Monthly Income (SSI, VA, Disability, Farm, other)

PART E: CERTIFICATION - The head of household or adult designee who completed this form must complete this certification section.

I certify (promise) that all information on this form is true, and that all income is reported to the best of my knowledge. I understand that this form may impact the amount of State or Federal funding allocated to my local school district. I understand that the information I have provided may be verified. (required) I promise

Printed Name of Adult Signing Form

Today's Date

Street Address (if available)

City

State

Zip Code

Email

Home Phone

Work Phone