Family Application For Free And Reduced Price School Meals 1 ...
School Year 2008-2009
_____F _____R _____D
Withdrew _____________
COMPLETE ONLY APPLICATION FOR YOUR HOUSEHOLD
ONE
Temp Free Expires _______
RCSD APP #
*45 Days*
FAMILY APPLICATION FOR FREE AND REDUCED PRICE SCHOOL MEALS
To apply for free and reduced price meals for your children, read the instructions on the back, complete only one form per household, sign your name and
return it to School Food Service Office. Call 336-4150 if you need help. For additional names, list on a sheet of paper and attach it to this application.
1. CHILDREN IN SCHOOL: (Complete a separate application for each foster child.)
Children's Names (Last, First, MI)
Grade/Teacher
School
2. FOSTER CHILD: If the above named child is the legal responsibility of a welfare agency or court, check this box.
List the child's personal use income:
(Write "0" if the child has no personal use income.) Skip to Part 5.
3. HOUSEHOLDS GETTING FOOD STAMPS OR TEMPORARY ASSISTANCE TO NEEDY FAMILIES (TANF): Complete this
section and sign the application in Part 5 OR submit a Direct Certification letter from the Office of Temporary and Disability Assistance or
Food Distribution Program on Indian Reservations (FDPIR). Complete a separate application for children with a different case number or
no case number. Write your case number as provided on your benefit letter, not the number on your benefit card.
Food Stamp Case #:
TANF/FDPIR Case #: _____________________________________
4. HOUSEHOLD MEMBERS & TOTAL HOUSEHOLD INCOME: If you did not give a food stamp or TANF case number, or submit a
Direct Certification letter, complete this part and all of part 5.
CURRENT INCOME/PAY PERIOD
Show how often each amount is received
Examples: $100.29/weekly, $100.29/bi-weekly, $100.29/2x per month, $100.29/monthly
See Examples
If pay period is not noted, the reviewing official will process the reported income amount as received WEEKLY.
Earnings From Work
Child Support,
Payments from
List the names of everyone in your household
Before deductions
Alimony, Etc.
Pension or Retirement
Other Income
Amount / How Often
Amount / How Often
Amount / How Often
Amount / How Often
1. ___________________________________
$ /
$ /
$ /
$ /
2. ___________________________________
$ /
$ /
$ /
$ /
3. ___________________________________
$ /
$ /
$ /
$ /
4. ___________________________________
$ /
$ /
$ /
$ /
5. ___________________________________
$ /
$ /
$ /
$ /
6. ___________________________________
$ /
$ /
$ /
$ /
7. ___________________________________
$ /
$ /
$ /
$ /
5. SIGNATURE: An adult household member MUST sign the application before it can be approved.
I certify that all of the information is true and that all income is reported. I understand that the information is being given for the school to receive federal
funds; that school officials may verify the information and that deliberate misrepresentation of the information may subject me to prosecution under
applicable State and federal laws, and my children may lose meal benefits.
SIGNATURE:___________________________________DATE:
SOCIAL SECURITY #___ ___ ___-___ ___-___ ___ ___ ___
______________________________________________________________________________________________________________
Home Telephone
Work Telephone Mailing Address
Zip Code
SOCIAL SECURITY NUMBER: If Part 4 is completed, the adult who signs the application must provide his/her Social Security number.
DO NOT WRITE BELOW THIS LINE - FOR SCHOOL USE ONLY
ANNUAL INCOME CONVERSION (ONLY CONVERT WHEN MULTIPLE FREQUENCIES ARE REPORTED ON APPLICATIONS):
WEEKLY X 52; EVERY 2 WEEKS X 26; TWICE A MONTH X 24;MONTHLY X 12
FOOD STAMP, TANF, Foster Child
INCOME HOUSEHOLD: Total Household Income/Frequency: __________________/______________________ Household Size: ____________
Application APPROVED for:
Free Meals
Reduced Price Meals
Temporary Free (expires in 45 days)___/___/___ Application DENIED
Date Notice Sent: __________________ Signature of Reviewing Official: __________________________________________ Date: _________________
APPLICATION INSTRUCTIONS
To apply for free and reduced price meals, submit a Direct Certification letter received from the Office of Temporary and Disability
Assistance OR complete only one application for your household using the instructions. Sign the application and return the application to the
School Food Service Office.
Please complete a separate application for each foster child. Call 336-4150 if you need help in completing this application.
Ensure that all information is provided. Failure to do so may result in an unnecessary delay in approving your application or a denial of benefits
for your child(ren).
PART 1
ALL HOUSEHOLDS MUST COMPLETE STUDENT INFORMATION.
PLEASE FILL OUT ONLY ONE
APPLICATION FOR YOUR HOUSEHOLD
(1)Print the names of the children for whom you are applying on one application. (For Foster Children, see Part 2)
(2)List their grade and school.
PART 2
HOUSEHOLDS WITH A FOSTER CHILD SHOULD COMPLETE THIS PART AND SIGN PART 5. A foster child
is the legal responsibility of a welfare agency or court. A separate application must be completed for each foster child.
(1)List the foster child's monthly "personal use" income. ("Personal Use" income is money given by the welfare office
identified by category for the child's personal use, such as an allowance, and all other money the child gets, such as
money from his/her family or money from the child's employment.) Write "0" if the foster child does not get "personal
use" income. SKIP PART 4. Do not list any other children, household members or income, or a social security number.
(2)A foster parent or other official representing the child must sign the application in PART 5.
PART 3
HOUSEHOLDS GETTING FOOD STAMPS, TANF OR FDPIR SHOULD COMPLETE THIS PART AND SIGN
PART 5. COMPLETE A SEPARATE APPLICATION FOR A CHILD/CHILDREN WITH A DIFFERENT CASE
NUMBER.
(1)List a current Food Stamp case number, TANF or FDPIR (Food Distribution Program on Indian Reservations) number.
Do not use the number on your benefit card. The case number is provided on your benefit letter.
(2)An adult household member must sign the application in PART 5. SKIP PART 4. Do not list names of household
members or income if you list a food stamp case number, TANF or FDPIR number.
PARTS 4 & 5 ALL OTHER HOUSEHOLDS MUST COMPLETE THESE PARTS AND ALL OF PART 5.
(1)Write the names of everyone in your household, whether or not they get income. Include yourself, the children you are
applying for, all other children, your spouse, grandparents, and other related and unrelated people in your household.
Use another piece of paper if you need more space.
(2)Write the amount of current income each household member receives, before taxes or anything else is taken out, and
indicate where it came from, such as earnings, welfare, pensions and other income. If the current income was more or
less than usual, write that person's usual income. Specify how often this income amount is received: weekly, bi-
weekly, monthly, 2 x per month. Changes in income during the school year no longer need to be reported.
(3)The value of any child care provided or arranged, or any amount received as payment for such child care or
reimbursement for costs incurred for such care under the Child Care and Development Block Grant, TANF and At Risk
Child Care Programs should not be considered as income for this program.
(4)The application must include the social security number of the adult who signs PART 5 if Part 4 is completed. If the
adult does not have a social security number, write "none". If you listed a food stamp, TANF or FDPIR number, or if
you are applying for a foster child, a social security number is not needed.
OTHER BENEFITS: Your child may be eligible for benefits such as Medicaid or Children's Health Insurance Program (CHIP). In order to determine if
your child is eligible, program officials need information from your free and reduced price meal application. Your written consent is required before any
information may be released. Please refer to the attached parent Disclosure Letter and Consent Statement for information about other benefits.
PRIVACY ACT STATEMENT
Section 9 of the National School Lunch Act requires that unless your children's food stamp, TANF or FDPIR case number is provided, you must include the
social security number of the adult household member signing the application, or indicate that the household member does not have a social security number.
The disclosure of a social security number is voluntary. However, if a social security number is not given or an indication is not made that the signer does not
have such a number, the application cannot be approved. The social security number may be used to identify the household member in carrying out efforts to
verify the correctness of information stated on the application. These verification efforts may be carried out through program reviews, audits and
investigations and may include contacting employers to determine income, contacting a food stamp or welfare office to determine current certification for
receipt of food stamps or other benefits, contacting the State employment security office to determine the amount of benefits received and checking the
documentation produced by household members to prove the amount of income received. These efforts may result in a loss or reduction of benefits,
administrative claims, or legal actions if incorrect information is reported.
DISCRIMINATION COMPLAINTS
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color,
national origin, sex, gender, or disability. To file a complaint, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW,
Washington, D.C. 20250-9410 or call (800) 795-3272 or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.
Letter to Parents for School Meal Programs
Dear Parent/Guardian:
Children need healthy meals to learn.The Rochester City School District offers healthy meals every school day.
Breakfast costs $.50 a day at elementary schools and $.60 a day at secondary schools. Lunch costs $.85 a day at elementary schools and
$1.10 a day at secondary schools. Children from households that meet federal income guidelines (outlined below) are eligible for free meals
or reduced price meals. Reduced price meals cost each eligible student $.25 for lunch and $.25 for breakfast. To apply for free or
reduced price meals, submit a Direct Certification letter from the NYS Office of Temporary and Disability Assistance OR
complete the enclosed application, sign it, and return it to the School Food Service Office as soon as possible. Please refer to the
guidelines contained in this letter when completing the application. We cannot approve an application that is not complete, so
be sure to fill out all required information.
1. Do I need to fill out an application for each child? No. Complete the application to apply for free or
reduced price meals. Do not fill out more than one application for your household.
2. Who can get free meals? Children in households getting Food Stamps or TANF and most foster children
can get free meals regardless of your income. Also, your children can get free meals if your
household income is within the free limits on the Federal Income Guidelines. Each foster child must be listed on a separate
application, with Part 2 completed and include an adult signature.
3. Can homeless, Runaway and migrant children get free meals?
Please call one of the programs below to see if your child(ren) qualify, if you have not been informed that they will get free meals.
Program For Homeless Students and Families
Brockport Migrant Education Outreach Program
The Family Learning Center
SUNY College at Brockport
30 Hart Street
350 Newcampus
Rochester, NY 14605
Brockport, NY 14420
(585) 262-8000
(585) 395-2356
4. Who can get reduced price meals? Your children can get low cost meals if your household income is within
the reduced price limits on the Federal Income Chart, shown on this application.
5. Should I fill out an application if I received a letter this school year saying my children are approved for free or reduced pice meals?
Please read the letter you received carefully and follow the instructions. Call the School Food Service Office at 336-4150 if you have questions
6. I get WIC, can my child(ren) get free meals? Children in households participating in WIC may be eligible for free or
reduced price meals. Please fill out an application.
7. Will the information I give be checked? The school may ask you at any time during the school year to verify your eligibility.
You will be notified, in writing, if you have been selected for Verification. School officials may ask you to send papers
showing that your child should receive free or reduce price meals at the time you applied.
8. If I don't qualify now, may I apply later? Yes. You may apply at any time during the school year if your
household size goes up, income goes down, or if you start getting Food Stamps, TANF or other benefits. If
you lose your job, your children may be able to get free or reduced price meals.
9. 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: Bill Williams, 835 Hudson Ave, Building #6, Rochester, NY 14621, (585)336-4118
10. May I apply if someone in my household is not a U.S. citizen? Yes. You or your child(ren) do not
.have to be a U.S. citizen to qualify for free or reduced price meals.
11. Who should I include as members of my household? You must include all people living in your
household, related or not (such as grandparents, other relatives, or friends). You must include yourself and
all children who live with you.
12. What if my income is not always the same? List the amount that you normally get. For example, if
you normally get $1000 each month, but you missed some work last month and only got $900, put down
that you get $1000 per month. If you normally get overtime, include it, but not if you get it only sometimes.
Income Chart: The following chart lists income levels according to household size and income levels received either
yearly, monthly or weekly. If your total household income is the same or less than the amounts on the Income Chart below, your children
may be eligible to receive free or reduced price meals.
REDUCED PRICE ELIGIBILITY INCOME CHART
Effective from July 1, 2008 to June 30, 2009
Household Size
Annual
Month
Twice-Monthly Bi-Weekly
Weekly
1...........................................
$19,240 $1,604
$ 802
$ 740
$ 370
2...........................................
25,900
2,159
1,080
997
499
3...........................................
32,560
2,714 1,357
1,253
627
4...........................................
39,220
3,269
1,635
1,509
755
5...........................................
45,880
3,824
1,912 1,765
883
6...........................................
52,540
4,379 2,190 2,021
1,011
7...........................................
59,200
4,934
2,467 2,277
1,139
8...........................................
65,860
5,489 2,745 2,534
1,267
For each additional family
member add....................... 6,660
555
278 257
129
How to Apply : To get free or reduced price meals for your children you may submit a Direct Certification letter
received from the NYS Office of Temporary and Disability Assistance, OR carefully complete one application for your
household and return it to the designated office. If you now receive food stamps, Temporary Assistance to Needy Families
(TANF) for any children, or participate in the Food Distribution Program on Indian Reservations (FDPIR), the application must
include the children's names, the household food stamp, TANF or FDPIR case number and the signature of an adult household
member. All children with the same case number may be listed on the same application. Separate applications are required for
children with different case numbers. If you do not list a food stamp, TANF or FDPIR case number for all the children for
whom you are applying, the application must include the names of everyone in the household, the amount of income each household
member, and how often it is received and where it comes from. It must include the signature of an adult household
member and that adult's social security number, or the word "none" if the adult does not have a social security number. An
application that is not complete cannot be approved. Contact your local Department of Social Services for your food stamp or
TANF case number or complete the income portion of the application.
Reporting Changes: The benefits that you are approved for at the time of application are effective for the entire
school year. You no longer need to report changes for an increase in income or decrease in household size, or if you
no longer receive food stamps.
Income Exclusions: The value of any child care provided or arranged, or any amount received as payment for such
child care or reimbursement for costs incurred for such care under the Child Care Development (Block Grant) Fund should not
be considered as income for this program.
Nondiscrimination Statement: This explains what to do if you believe you have been treated unfairly. In accordance
with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of
race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write: USDA, Director,
Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (800) 795-3272
or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.
Meal Service to Children With Disabilities : Federal regulations require schools and institutions to serve meals at no
extra charge to children with a disability which may restrict their diet. A student with a disability is defined in 7CFR Part
15b.3 of Federal regulations, as one who has a physical or mental impairment which substantially limits one or more major life
activities. Major life activities are defined to include functions such as caring for one's self, performing manual tasks, walking,
seeing, hearing, speaking, breathing, learning, and working. You must request the special meals from the school and provide
the school with medical certification from a medical doctor. If you believe your child needs substitutions because of a
disability, please get in touch with us for further information, as there is specific information that the medical certification must
contain.
Confidentiality: The United States Department of Agriculture has approved the release of students names and
eligibility status, without parent/guardian consent, to persons directly connected with the administration or enforcement of
federal education programs such as Title I and the National Assessment of Educational Progress (NAEP), which are United
States Department of Education programs used to determine areas such as the allocation of funds to schools, to evaluate
socioeconomic status of the school's attendance area, and to assess educational progress. Information may also be released to
State health or State education programs administered by the State agency or local education agency, provided the State or
local education agency administers the program, and federal State or local nutrition programs similar to the National School
Lunch Program. Additionally, all information contained in the free and reduced price application may be released to persons
directly connected with the administration or enforcement of programs authorized under the National School Lunch Act
(NSLA) or Child Nutrition Act (CNA); including the National School Lunch and School Breakfast Programs, the Special Milk
Program, the Child and Adult Care Food Program, Summer Food Service Program and the Special Supplemental Nutrition
Program for Women Infants and Children (WIC); the Comptroller General of the United States for audit purposes, and
federal, State or local law enforcement officials investigating alleged violation of the programs under the NSLA or CNA.
The disclosure of eligibility information not specifically authorized by the NSLA requires a written consent statement
from the parent/guardian.
We will let you know when your application is approved or denied.
Sincerely,
Rochester City School District School Food Services
