FREE AND REDUCED-PRICE SCHOOL MEALS FORM

Dear Parent/Guardian:

Children need healthy meals to learn. "School District name" Public School offers healthy meals every school day. Breakfast costs (.40); lunch costs (.60). Your children may qualify for free meals or for reduced-price meals. Reduced-price is (.25) for breakfast and (.25) for lunch. This packet includes an application for free or reduced-price meal benefits and a set of detailed instructions. Below are some common questions and answers to help you with the application process.

WHO CAN GET FREE OR REDUCED-PRICE MEALS?

All children in households receiving benefits from (Supplemental Nutrition Assistance Program [SNAP]), (Food Distribution Program on Indian Reservations [FDPIR], or (Temporary Assistance for Needy Families [TANF]) are eligible for free meals.
Foster children who are under the legal responsibility of a foster care agency or court are eligible for free meals.
Children participating in their school’s Head Start program are eligible for free meals.
Children who meet the definition of homeless, runaway, or migrant are eligible for free meals.
Children may receive free or reduced-price meals if your household’s income is within the limits on the Federal Income Eligibility Guidelines. Your children may qualify for free or reduced-price meals if your household income falls at or below the limits on this chart.

FEDERAL ELIGIBILITY INCOME CHART for School Year: 2017

Household Size	Yearly	Monthly	Weekly
1	21,978	1,832	423
2	29,637	2,470	570
3	37,296	3,108	718
4	44.955	3,747	865
5	52,614	4,385	1,012
6	60,273	5,023	1,160
7	67,951	5,663	1,307
8	75,647	6,304	1,455
Each additional person:	7,696	642	148

2.HOW DO I KNOW IF MY CHILDREN QUALIFY AS HOMELESS, MIGRANT, OR RUNAWAY?

Do the members of your household lack a permanent address? Are you staying together in a shelter, hotel, or other temporary housing arrangement? Does your family relocate on a seasonal basis? Are any children living with you who have chosen to leave their prior family or household? If you believe children in your household meet these descriptions and have not been told your children will get free meals, please call or e-mail: ("School District name", "contact name").

3.DO I NEED TO FILLOUT AN APPLICATION FOR EACH CHILD?

No. Use one Free and Reduced-PriceSchool Meals Application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to: "Contact Name", "School Address" "School Phone number", "School Contact Email".

4.SHOULD I FILL OUT AN APPLICATION IF I RECEIVED A LETTER THIS SCHOOL YEAR SAYING MY CHILDREN ARE ALREADY APPROVED FOR FREE MEALS?

No, but please read the letter you got carefully and follow the instructions. If any children in your household were missing from your eligibility notification, contact "Contact Name", "School Address" "School Phone number", immediately.

5. CAN I APPLY ONLINE?

Yes! You are encouraged to complete an online application instead of a paper application if you are able. The online application has the same requirements and will ask you for the same information as the paper application. Visit "School Website"/a> to begin or to learn more about the online application process. Contact:"Contact Name", "School Address" "School Phone number", "School Contact Email" at if you have any questions about the online application.

6. MY CHILD’S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT A NEW ONE?

Yes. Your child’s application is only good for that school year and for the first few days of this school year, through 09-01-2016. You must send in a new application unless the school told you that your child is eligible for the new school year. If you do not send in a new application that is approved by the school or you have not been notified that your child is eligible for free meals, your child will be charged the full price for meals.

7. I GET WIC. CAN MY CHILDREN GET FREE MEALS?

Children in households participating in WIC MAY be eligible for free or reduced-price meals. Please send in an application.

8. WILLTHE INFORMATION I GIVE BE CHECKED?

Yes. We may also ask you to send written proof of the household income you report.

9. IF I DO NOT QUALIFY NOW, MAY I APPLY LATER?

Yes, you may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free and reduced-price meals if the household income drops below the income limit.

10. WHAT IF I DISAGREE WITH THE SCHOOL’S DECISION ABOUT MY APPLICATION?

You should talk to school officials. You also may ask for a hearing by calling or writing to:"School District name", "school Address" "school Phone numbers".

11. MAY I APPLY IF SOMEONE IN MY HOUSEHOLD IS NOT A UNITED STATES (U.S.) CITIZEN?

Yes. You, your children, or other household members do not have to be U.S. citizens to apply for free or reduced-price meals.

12. WHAT IF MY INCOME IS NOT ALWAYS THE SAME?

List the amount that you NORMALLY receive. For example, if you normally make $1000 each month, but you missed some work last month and only made $900, put down that you made $1000 per month. If you normally get overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income.

13. WHAT IF SOME HOUSEHOLD MEMBERS HAVE NO INCOME TO REPORT?

Household members may not receive some types of income we ask you to report on the application or may not receive income at all. Whenever this happens, please write a 0 in the field. However, if any income fields are left empty or blank, those will ALSO be counted as zeroes. Please be careful when leaving income fields blank, as we will assume you MEANT to do so.

14. WE ARE IN THE MILITARY. DO WE REPORT OUR INCOME DIFFERENTLY?

Your basic pay and cash bonuses must be reported as income. If you get any cash value allowances for off-base housing, food, or clothing, or receive Family Subsistence Supplemental Privatization Initiative, do not include your housing allowance as income. Any additional combat pay resulting from deployment is also excluded from income.

15. WHAT IF THERE IS NOT ENOUGH SPACE ON THE APPLICATION FOR MY FAMILY?

Contact:"School District name", "School Phone Number", to receive a second application.

16. MY FAMILY NEEDS MORE HELP. ARE THERE OTHER PROGRAMS WE MIGHT APPLY FOR?

To find out how to apply for (SNAP) or other assistance benefits, contact your local assistance office or call 1-866-411-1877.

If you have other questions or need help, call "School Phone Number".

Sincerely,

"School Contact"

Please Fill Out The 2017-2018 free and reduced form Below

HOW TO APPLY FOR FREE AND REDUCED-PRICE SCHOOL MEALS

Please use these instructions to help you fill out the application for free or reduced-price school meals. You only need to submit ONE application per household, even if your children attend more than one school in "School District name". The application must be filled out completely to certify your children for free or reduced-price school meals.

Please follow these instructions in order! Each step of the instructions is the same as the steps on your application. If at any time you are not sure what to do next, please contact "School District name", "Contact Name", "School Address" "School Phone number", "School Contact Email".

STEP 1: LIST ALL HOUSEHOLD MEMBERS WHO ARE INFANTS, CHILDREN, AND STUDENTS UP TO AND INCLUDING GRADE 12

Tell us how many infants, children, and school students live in your household. They do NOT have to be related to you to be a part of your household Copy

Who should I list here? When filling out this section, please include ALL members in your household who are:

�Children aged 18 or under AND are supported with the household's income.

�In your care under a foster arrangement or qualify as homeless, migrant, or runaway youth.

�Students attending "School District name", regardless of age.

A. List each child's name. For each child, print his/her first name, middle initial, and last name. Use one line of the application for each child. If there are more children present than lines on the application, attach a second piece of paper with all required information for the additional children.

B. Is the child a student at "School District name"? Mark Yes or No under the column titled Student to tell us which children attend "School District name".

C. Do you have any foster children? If any children listed are foster children, mark the Foster Child box next to the child's name. If you are ONLY applying for foster children, after completing STEP 1, skip to STEP 4 of the application and these instructions. If you are applying for both foster and nonfoster children, go to Step 3. Foster children who live with you may count as members of your household and should be listed on your application.

D. Are any children homeless, migrant, or runaway? If you believe any child listed in this section may meet this description, please mark the Homeless, Migrant, Runaway box next to the child's name and complete all steps of the application.

STEP 2: DO ANY HOUSEHOLD MEMBERS (INCLUDING YOU) CURRENTLY PARTICIPATE IN ONE OR MORE OF THE FOLLOWING ASSISTANCE PROGRAMS: SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP), TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF), OR FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS (FDPIR)? If Yes, record the proper case number (only one per household) in the box. Skip to STEP 4.

If anyone in your household participates in the assistance programs, your children are ELIGIBLE for free school meals

If NO ONE in your household participates in any of the above programs:

�Skip to STEP 3 on these instructions and STEP 3 on your application. �Leave STEP 2 blank.

STEP3: REPORT INCOME FOR ALL HOUSEHOLD MEMBERS

A. Report all income earned by children. Refer to the chart titled Sources of Income for Children in these instructions, and report the combined gross income for ALL children listed in STEP 1 in your household in the box marked Total Child Income. Only count foster children�s income if you are applying for them together with the rest of your household. It is optional for the household to list foster children living with them as part of the household.

What is Child Income? Child income is money received from outside your household that is paid DIRECTLY to your children. Many households do not have any child income. Use the chart below to determine if your household has child income to report.

Sources of Income for Children

Sources of Child Income

� Earnings from work example: A child has a job where he/she earns a salary or wages

� Social Security �Disability payments �Survivor�s benefits

Example: A child is blind or disabled and receives social security benefits, A parent is disabled, retired, or deceased, and his/ her child receives social security benefits.

Income from persons OUTSIDE the household example: A friend or extended family member REGULARLY gives a child spending money

Income from any other source example: A child receives income from a private pension fund, annuity, or trust.

FOR EACH ADULT HOUSEHOLD MEMBER:

Who should I list here? When filling out this section, please include ALL ADULT members in your household who are: Living with you and share income and expenses, even if not related and even if they do not receive income of their own.

Do NOT include people who: Live with you but are not supported by your household's income AND do not contribute income to your household. Children and students already listed in STEP 1.

How do I fill in the income amount and source?

FOR EACH TYPE OF INCOME: � Use the charts in this section to determine if your household has income to report. � Report all amounts in gross income ONLY. Report all income in whole dollars. Do not include cents. � Gross income is the total income received before taxes or deductions. � Many people think of income as the amount they take home and not the total gross amount. Make sure that the income you report on this application has NOT been reduced to pay for taxes, insurance premiums, or any other amounts taken from your pay.� Write a 0 in any fields where there is no income to report. Any income fields left empty or blank will be counted as zeroes. If you write 0 or leave any fields blank, you are certifying (promising) that there is no income to report. If local officials have known or available information that your household income was reported incorrectly, your application will be verified for cause. � Mark how often each type of income is received using the check boxes to the right of each field.

B. List adult household members' names. Print the name of each household member in the boxes marked Names of Adult Household Members (First and Last). Do not list any household members you listed in STEP 1. If a child listed in STEP 1 has income, follow the instructions in STEP 3, Part A.

C. Report earnings from work. Refer to the chart titled Sources of Income for Adults in these instructions, and report all income from work in the Earnings From Work field on the application. This is usually the money received from working at jobs. If you are a self-employed business or farm owner, you will report your net income. This is calculated by subtracting the total operating expenses of your business from its gross receipts or revenues.

D. Report income from public assistance/child support/alimony. Refer to the chart titled Sources of Income for Adults in these instructions, and report all income that applies in the Public Assistance/Child Support/Alimony field on the application. Do not report the value of any cash value public assistance benefits NOT listed on the chart. If income is received from child support or alimony, only court-ordered payments should be reported here. Informal regular payments should be reported as Other income in the next part.

E. Report income from pensions/retirement/all other income. Refer to the chart titled Sources of Income for Adults in these instructions, and report all income that applies in the Pensions/Retirement/All Other Income field on the application.

F. Report total household size. Enter the total number of household members in the field TotalHousehold 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.

G. 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 his/her 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 member has a social security number, leave this space blank and mark the box to the right labeled Check if no SSN.

Sources of Income for Adults

Earnings From Work: � 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.

Public Assistance/Alimony/Child Support: � Unemployment benefits � Worker�s compensation� SupplementalSecurityIncome (SSI)� Cash assistance from state or local government� Alimony payments� Child support payments� Veteran�s benefits.

Pensions/Retirement/All Other Income: � 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.

STEP 4: CONTACT INFORMATION AND ADULT SIGNATURE: All applications must be signed by an adult member of the household. By signing the application, that household member is promising that all information has been truthfully and completely reported. Before completing this section, please also make sure you have read the privacy and civil rights statements on the application.

A. Provide your contact information. Write your current address in the fields provided if this information is available. If you have no permanent address, this does not make your children ineligible for free or reduced-price school meals. Sharing a phone number, e-mail address, or both is optional, but helps us reach you quickly if we need to contact you.

B. Print and sign your name. Print your name in the box Printed Name of Adult Completing the Form. Electronically sign your name in the box Signature of Adult Completing the 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.

C. Today's date. In the space provided, write today's date.

D. Share children's racial and ethnic identities (optional). On this application, we ask you to share information about your children's race and ethnicity. This field is optional and does not affect your children's eligibility for free or reduced-price school meals.

2016-2017 Application for Free and Reduced-Price School Meals. Complete one application per household.

STEP 1 List ALL household members who are infants, children, and students, up to and including Grade 12 (if more spaces are required for additional names, call "School District name", "School Phone Number".

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

Child's First Name

Child's Last Name

School Name

Grade

Birth Date

Student?

Reaquired field: Yes

Reaquired field: No

Foster Child

Homeless, Migrant, Runaway

Child's First Name

Child's Last Name

School Name

Grade

Birth Date

Student?

Yes

Foster Child

Homeless, Migrant, Runaway

Child's First Name

Child's Last Name

Birth Date

School Name

Grade

Student?

Yes

Foster Child

Homeless, Migrant, Runaway

Child's First Name

Child's Last Name

Birth Date

School Name

Grade

Student?

Yes

Foster Child

Homeless, Migrant, Runaway

Child's First Name

Child's Last Name

School Name

Grade

Birth Date

Student?

Yes

Foster Child

Homeless, Migrant, Runaway

Child's First Name

Child's Last Name

School Name

Grade

Birth Date

Student?

Yes

Foster Child

Homeless, Migrant, Runaway

STEP 2 Do any household members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?

If you do not receive SNAP, TANF, or FDPIR benefits, complete STEP 3. If you receive SNAP, TANF, or FDPIR benefits, write a case number here, then go to STEP 4. (Do not complete STEP 3.)

Case Number:

STEP 3 Report income for ALL household members (Skip this step if you answered YES to STEP 2)

Please read How to Apply for Free and Reduced-Price School Meals for more information. The Sources of Income for Children section will help you with the Child Income question. The Sources of Income for Adults section will help you with the All Adult Household Members section.

A. Child Income

Child Income

How Often

Weekly

Bi- weekly

2x Month

Monthly

B. All Adult Household Members (IncludingYourself) List all household members not listed in STEP 1 (including yourself), even if they do not receive income. For each household member listed, if he/she receives income, report total 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.

Name of Adult Household Member (First and Last)

Earnings From Work

How Often

Weekly

Bi- weekly

2x Month

Monthly

Public Assistance/Child Support/Alim

How Often

Weekly

Bi- weekly

2x Month

Monthly

Pensions/ Retirement/All Other Incomes

How Often

Weekly

Bi- weekly

2x Month

Monthly

Name of Adult Household Member (First and Last)

Earnings From Work

How Often

Weekly

Bi- weekly

2x Month

Monthly

Public Assistance/Child Support/Alim

How Often

Weekly

Bi- weekly

2x Month

Monthly

Pensions/ Retirement/All Other Incomes

How Often

Weekly

Bi- weekly

2x Month

Monthly

Name of Adult Household Member (First and Last)

Earnings From Work

How Often

Weekly

Bi- weekly

2x Month

Monthly

Public Assistance/Child Support/Alim Copy

How Often

Weekly

Bi- weekly

2x Month

Monthly

Pensions/ Retirement/All Other Incomes

How Often

Weekly

Bi- weekly

2x Month

Monthly

Name of Adult Household Member (First and Last)

Earnings From Work

How Often

Weekly

Bi- weekly

2x Month

Monthly

Public Assistance/Child Support/Alim

How Often

Weekly

Bi- weekly

2x Month

Monthly

Pensions/ Retirement/All Other Incomes

How Often

Weekly

Bi- weekly

2x Month

Monthly

Name of Adult Household Member (First and Last)

Earnings From Work

How Often

Weekly

Bi- weekly

2x Month

Monthly

Public Assistance/Child Support/Alim

How Often

Weekly

Bi- weekly

2x Month

Monthly

Pensions/ Retirement/All Other Incomes

How Often

Weekly

Bi- weekly

2x Month

Monthly

Total Household Members (Children and Adults)

Last Four Digits of Social Security Number (SSN) of Primary Wage Earner or Other Adult Household Member

Check if No SSN

STEP 4 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.

Reaquired field: Street Address, Apt #

Address

City

State / Province / Region

Zipcode Min: 1 Max: 5

Country

Daytime Phone

E-Mail Address

Printed Name of Adult Completing the Form

I understand that checking this box constitutes a legal signature.*

Reaquired field:

Electronic signature of Adult Completing the Form *

Today's Date

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.

Ethnicity (Check One):

Hispanic or Latino

Not Hispanic or Latino

Race (Check One or More):

American Indian orAlaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

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.

In accordance with federal civil rights law and United States Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, office, employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliations for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language [(ASL)] should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing, or have speech disabilities may contact USDA through the Federal Relay Service at 800-877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at , or at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call 866-632-992. Submit your completed complaint form or letter to USDA by mail at U.S.Department of Agriculture,Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington,DC 20250-0410, by fax 202-690-7442, or e-mail at .

USDA is an equal opportunity provider and employer.

Oklahoma State Department of Education Eligibility Documentation Section, July 2015

SHARING INFORMATION WITH MEDICAID/SOONERCARE

Dear Parent/Guardian:

If your children get free or reduced-price school meals, they MAY also be able to get free or low-cost health insurance through Medicaid or SoonerCare. Children with health insurance are more likely to get regular health care and are less likely to miss school because of sickness.

Because health insurance is so important to children's well-being, the law allows us to tell Medicaid SoonerCare that your children are eligible for free and reduced-price school meals unless you tell us not to. Medicaid and SoonerCare only use the information to identify children who may be eligible for these programs. Program officials may contact you to offer to enroll your children. Filling out the Application for Free and Reduced-Price Meals does not automatically enroll your children in health insurance.

If you do not want us to share your information with Medicaid or SoonerCare, fill out the form below . (Sending in this form will not change whether your children get free or reduced-price school meals).

No! I DO NOT want information from my Application for Free and Reduced-Price School Meals shared with Medicaid or SoonerCare.

If you checked No, fill out the form below to ensure that your information is NOT shared for the child listed below:

Child's Name:

School:

Child's Name:

School:

Child's Name:

School:

Child's Name:

School:

Child's Name:

School:

Child's Name:

School:

Email a copy to

optional

Required Fields