Part 1. Children in School (Use a separate application for each foster child)

Names of ALL children in School
(PLEASE PRINT CLEARLY)

School Name
(List Correct School each
 child attends)

GRADE

FOOD STAMP
or TANF CASE # (If any)

Part 2. If the child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your school, homeless liaison, migrant coordinator at phone

Part
 3. Foster Child

If this application is for a child who is the legal responsibility of a welfare agency or court, check this box  □ and then  list the amount of the child’s personal use monthly income:  $__________. Skip to Part 5.

Part
 4. Total Households GROSS Income – You must tell us how much and how often

1. Name
(List EVERYONE in Household)

2. Last month’s income and how often it was received

Example:   $100/monthly   $100/twice a month    $100/every other week  $100/weekly

3. Check
if NO income

Earnings from work before deductions

Welfare, child support, alimony

Pensions, retirement, Social Security

Other

(Example)
Jane Smith

$200/weekly_____

$150/weekly_____

$100/monthly_____

$______/________

q               

$______/_______

 

$______/________

$______/_____

$______/____

q               

$______/_______

 

$______/________

$______/_____

$______/____

q               

$______/_______

 

$______/________

$______/_____

$______/____

q               

$______/_______

 

$______/________

$______/_____

$______/____

q               

$______/_______

 

$______/________

$______/_____

$______/____

q               

$______/_______

 

$______/________

$______/_____

$______/____

q               

Part 5. Signature and Social Security Number (Adult must sign)

An adult household member must sign the application. If Part 3 is completed, the adult signing the form must also list his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on the back of this page.)

I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted.  I understand that school officials may inform other child nutrition, health and education programs, including the Department of Transitional Assistance’s Food Stamp Program (DTA), Women Infant and Children (WIC), and Mass HEALTH of information on my form to determine benefits for those programs or for funding and/or evaluation purposes.                        Date:  _____________

Sign here: X_________________________________        Print Name:  _________________________________________

 

Address______________________________________ City/State/Zip ________________________   

 

Social Security Number:  __ __ __ - __ __ - __ __ __ __    q I do not have a Social Security Number

Home Telephone #  (     )             -                                   Work Telephone # (     )         -

Part 6. Children’s racial and ethnic identities (optional)

Mark one or more racial identities:

q       Asian


 

q       Black or
African American

q       American Indian or Alaska Native

q       Native Hawaiian or
Other Pacific Islander

q       White

q       Other

Mark one ethnic identity:

q       Hispanic or Latino

q       Not Hispanic or Latino

Don’t fill out this part. This is for school use only.

Monthly Income Conversion: Weekly x 4.33, Every 2 Weeks x 2.15, Twice A Month x 2

Total Income: ________         Household size: ___           FS/TANF: ___              Date Withdrawn: ________

Eligibility:         FREE □                      REDUCED □                     DENIED  □    Reason: _______________________

Temporary: Free  □  Reduced  □  Time Period: _________ (expires after __ days)

Determining Official’s Signature: _________________________________             Date: ________

Confirming Official’s Signature:  ___________________  Date:  _________  Follow-up Official’s Signature: ______________________  Date: ________