Guide to processing free and reduced price school meal applications

              Guide to Processing
Free and Reduced Price
School Meal Applications
United States Department of Agriculture
Food and Nutrition Service
Midwest Region
August 1991
L
GUIDE TO PROCESSING
FREE AND REDUCED PRICE
SCHOOL MEAL APPLICATIONS
All Programs of the U.S. Department of Agriculture are available to everyone without
regard to race, color, national origin, age, sex or handicap. If anyone believes they
have been discriminated against, they should write immediately to the Secretary of
Agriculture, Washington D.C., 20250.
TABLE OF CONTENTS
Introduction ............................................................................................................................ .
Application Requirements ..................................................................................................... .
Requirements for Food Stamp/ AFDC Applications................................................. 3
Requirements for Income Applications..................................................................... 4
Example Applications...................................................... ....................................................... 5
Incomplete Social Security Number........................................................ ..................... 6-7
Missing Social Security Number............................................................... ................... 8-9
Student Signs His Application...................................................................................... 10-11
Missing Adult Signature............................................................................................... 12-13
Missing Income Information....................................................................................... 14-15
Missing Food Stamp or AFDC Case Number............................................................... 16-17
Missing Child's Name................................................................................................... 18-19
Application Contains Both Case Number and Income Information............................ 20-21
Missing Income Information (foster child)....... ........................................................ 22-23
Zero Income................................................................................................ ................ 24-25
Household Applying for AFDC (or Food Stamp) Benefits......................................... 26-27
Missing Household Members' Names........................................................................... 28-29
Household Expects Less Income.................................................................................. 30-31
Household Expects Increase in Family Size................................................................. 32-33
Income Conversion Problems...................................................................................... 34-37
Denying Applications.............................................................................................................. 39
Appendices
Appendix A: Sample Notification Letter................................................................................... 43
Appendix B: Income Eligibility Guidelines.............................................................................. 45
Appendix C: Income Conversion............................................................................................... 47
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
INTRODUCTION
INTRODUCTION
The purpose of this booklet is to p·rovide assistance to schools and School
Food Authorities in the basic steps to processing applications for free and
reduced price meal benefits. The booklet is divided into three sections.
The first section lists the information required on all applications.
Requirements for categorically eligible applications (applications which report
Food Stamp or AFDC case numbers) are listed separately from the
requirements for income applications (applications which provide household
size and income information.)
The second section provides examples of some of the more common problems
found when processing applications. - For each problem application, solutions
are offered.
The third section gives information on how and when to deny an application.
In addition there are three appendices. They are a sample notification letter,
the income eligibility guidelines which were used to process the applications in
this booklet, and an income conversion chart.
We hope this material proves useful to schools when processing free and
reduced price applications. However, if more in-depth information regarding
free and reduced price applications is needed, please consult a copy of the
Eligibility Guidance for School Programs or contact your state agency.
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICATION REQUIREMENTS
APPLICATION REQUIREMENTS
/
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICATION REQUIREMENTS
Food Stamp/ AFDC
Applications
3
If a household submits an application which indicates that it
receives food stamps or AFDC, the following information
must be provided on the application before it can be
processed:
• Name of Child;
• Food Stamp or AFDC case number;
• Signature of adult household member.
This is the only information required from a household
receiving food stamp or AFDC benefits.
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
4 APPLICATION REQUIREMENTS
Income
Applications
If a household submits an application which provides income
information such as earnings from wages, social security, etc.,
the following information must be provided before the
application can be processed:
• Names of ALL household members;
• Social security number of the adult who signs the
application; or the word "none" if that person does
not have a social security number;
• Monthly income, by person, by source;
• Signature of an adult household member.
If any of this information is missing, the application cannot
be processed. The missing information must be obtained
before an eligibility determination can be made.
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
EXAMPLE APPLICATIONS 5
EXAMPLE APPLICATIONS
The following applications provide examples of some of the more common
problems encountered when processing free and reduced price applications.
Each application has ONLY ONE problem which is clearly defined and circled
in red. The page following each appHcation provides one or more solutions for
correcting each problem.
*****IMPORTANT*****
The example applications which follow were processed using the income
eligibility guidelines located in Appendix B of this booklet and are designed for
use with this booklet only. DO NOT USE THESE INCOME ELIGffiiLITY
GUIDELINES TO PROCESS YOUR APPLICATIONS.
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICATION FOR FREE AND REDUCED PRICE MEALS
To apply for free and !educed price meals, complete this application, sign your name and return the application to the school.
• Call the school If you need help at # .
1 Print STUDENT INFORMATION: 2 List the child's FOOD STAMP or AFDC case number, if any:
NAME GRADE NAME OF SCHOOL FOOD STAMP NUMBER OR AFDC NUMBER
ALlCE 0E"ASLfY 5 JEFFERSoN
3 FOSTER .CHILD: Ust the child's monthly personal use income. Write •o• if the child has no personal use income: $ ___ _
4 HOUSEHOLD MEMBERS AND MONTHLY INCOME: If you gave a food stamp or AFDC case number for the child, skip to PART s.
Gross MONTHLY Earnings MONTHLY Welfare MONTHLY
NAMES OF HOUSEHOLD MEMBERS (Before Deductions) Payments, Child Payments from
Support, Alimony Pensions, Retirement,
Job 1 Job 2 Social Security 6-r<A ~IE 8£A SL£'/ $ $ $ lit, $
TED 8EASLE'I $ 5'00 $ $ $
JOE f!JEASLE'/ $ $ $ $
Al.rdE f?JEASLE.'/ $ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
5 SIGNATURE AND SOCIAL SECURITY NUMBER: 1 certify that all of the above information is true and
is reported. I understand that this information is being given for the receipt of Federal funds; that school officials
application; and that deliberate misrepresentation of the information may subject me to prosecution under ii~~m~;a;u;
X ~ o~#fi:ld Member
HOME TELEPHONE NO. --------WORK TELEPHONE NO. -------
Any Other
MONTHLY
Income
$
$
$
$
$
$
$
STREET/APT. NO CITY/STATE/ZIP -------------DATE ----
6 RACE: Please check the racial or ethnic identity of your child. You are not required to answer this question.
_ White, not Hispanic _ Black, not Hispanic _Hispanic Asian/Pacific Islander American Indian/Alaskan Native
*Privacy Act Statement: Section 9 of the National School Lunch act requires that, unless your child's food stamp or AFDC 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. Provision of a social security number is not mandatory, but 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 AFDC 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 Joss or reduction of benefits, administrative claims or legal actions if incorrect information is reported.
FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 TWICE A MONTH X 2
Total household size: ------ Monthly Income------ Food stamp __ _ AFDC/ADC
Bigibility determination: Approved Free __ Approved Reduced Price __ Denied Temporary until: ---­Reason
for denial: Income too high__ Incomplete application__ Other-------------
Until: ___ _
Change In status: --------------------------- Date withdrawn: ___ _
Reason
Signature of determining official:
Date
Date vernication notice sent Response due from household: Second notice sent ___ _
Date:
Verifteation result No change __ Free to Reduced Price Free to Paid Reduced Price to Free Reduced Price to Paid
Until: ____ _
Reason for eligibility change: Income __ Household size __ Refused to cooperate __ Char-Qe In food stamp/AFDC __ Other ----------
Date ' notice of change' sent to perenl/guardian: ___ _
Signature of vereying official:--------------------------- Date: ___ _
EXAMPLE APPLICATIONS
BEASLEY APPLICATION
PROBLEM: The Beasley application cannot be approved
because Gracie Beasley did not provide a complete social
security number. The number she provided has five digits
instead of nine. Therefore, the number is invalid and
should be considered missing.
SOLUTION: You have three options:
1. You may contact the household either by phone or in writing to
obtain Gracie's complete social security number. If the household
gives you the social security number on the phone, or sends it to
you, enter the number directly on the application in the space for
Gracie's social security number. Be sure to date and initial any
information you write on the application.
OR
2. You may return the application to the household. Instruct the household
to provide the missing information and return it to the school as soon as
possible.
OR
3. You may deny the application. (See page 39 for further information on
denying applications.)
Remember, an income application cannot be approved until you receive either 1) a
complete social security number or 2) information indicating that the adult does not have
one.
7
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICATION FOR FREE AND REDUCED PRICE MEAI.S
To apply for free and-reduced price meals, complete this application, sign your name and return the application to the school.
Call the school If you need help at # ______ _
1 Print STUDENT INFORMATION: 2 List the child's FOOD STAMP or AFDC case number, if any:
NAME
T~AC.E'/ ?AVILLA
GRADE NAME OF SCHOOL FOOD STAMP NUMBER OR AFDC NUMBER
B HARPE~
3 FOSTER. CHILD: Ust the child's monthly personal use income. Write "0" if the child has no personal use income: $
4 HOUSEHOLD MEMBERS AND MONTHLY INCOME: If you gave a food stamp or AFDC case number for the child, skip to PART s.
Gross MONTHLY Earnings MONTHLY Welfare MONTHLY
NAMES OF HOUSEHOLD MEMBERS (Before Deductions) Payments, Child Payments from
Support, Alimony Pensions, Retirement,
SoPHtE PAVI~LA
Job 1 Job 2 Social Security
$ '"50 $ $ $
(!,AJ..IO'{ PATJIL.LA $ $ $ $
SriSI~ Pl'rVt~lA $ $ $ $
TR..At!..E'/ PA 1/1 L.L.It $ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
5 SIGNATURE AND SOCIAL SECURITY NUMBER: 1 certify that all of the above information is true
is reported. I understand that this information is being given for the receipt of Federal funds; that school
appli:ation; a~hat delibe~ate mis;p~the information may subject me to prosecution under
Si~dult Household Member
HOME TELEPHONE NO. -------- WORK TELEPHONE NO. -------
Any Other
MONTHLY
Income
$
$
$
$
$
$
$
STREET/APT. NO--------------- CITY/STATE/ZIP------------- DATE ___ _
6 RACE: Please check the racial or ethnic identity of your child. You are not required to answer this question.
_ White, not Hispanic _ Black, not Hispanic _Hispanic Asian/Pacific Islander American Indian/Alaskan Native
*Privacy Act Statement: Section 9 of the National School Lunch act requires that, unless your child's food stamp or AFDC 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. Provision of a social security number is not mandatory, but 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 AFDC 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.
FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 TWICE A MONTH X 2
Total household size: Monthly income Food stamp AFDC/ADC
Eligibility determination: Approved Free __ Approved Reduced Price __ Denied Temporary until: ___ _ Until:----- Until:-----
Reason for denial: Income too high__ Incomplete application__ Other-------------
Change in status: ---------------------------- Date withdrawn: ____ _
Reason
Signature of determining official:
Date verijication notice sent ___ _ Response due from household: ___ _
Verification result: No change __ Free to Reduced Price Free to Paid
Date
Second notice sent ---­Reduced
Price to Free
Date:
Reduced Price to Paid
Reason for eligibility change: Income __ Household size Refused to cooperate__ Change in food stamp/AFDC __ Other----------
Date 'notice of change' sent to parent/guardian: ____ _
Signature of veritying official:----------------------------- Date: ___ _
EXAMPLE APPLICATIONS
PADILLA APPLICATION
PROBLEM: The Padilla application cannot be approved
because there is no social security number. The social security
number of the adult who signs the application is required.
SOLUTION: You have three options:
9
a 0
/~-- ()
I. You may contact the Padilla household either by phone or in writing to obtain the missing
social security number. If the household gives you the social security number on the phone or
sends it to you, enter the number directly on the application in the space provided. If the
OR
household informs you that the adult who
signed the application does not have a social
security number, you should write the word
"NONE" in the space provided. Be sure to
date and initial any information you write on
the application.
OR
2. You may return the application to the
household. Instruct the household to
provide the missing information and
return it to the school as soon as possible.
3. You may deny the application. (See page 39 for further information on denying applications.)
Remember, an application cannot be approved until you receive either I) a complete social
security number or 2) information indicating that the adult who signed the application does not
have a social security number.
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICATION FOR FREE AND REDUCED PRICE MEALS
t the child's FOOD STAMP or AFDC case number, if any:
SCHOOL FOOD STAMP NUMBER OR AFDC NUMBER tom .s.
Write "0" if the child has no personal use income: $ ____ .
4 HOUSEHOLD MEMBERS AND MONTHLY INCOME: If you gave a food stamp or AFDC case number for the child, skip to PART s.
Gross MONTHLY Earnings MONTHLY Welfare MONTHLY Any Other
NAMES OF HOUSEHOLD MEMBERS (Before Deductions) Payments, Child Payments from MONTHLY
Support, Alimony Pensions, Retirement, Income
JDJ.}N fJE" H fZE"l.$
Job 1 Job 2 Social Security
$ BOO $ $ $ $
A~N € fJEHf!.~~ $ bOO $ $ $ $
CJ.lR.r~ &EHitf.NS $ $ $ $ $
1JA\/r 0 f?>E"Hf.C.N.$ $ $ $ $ $
$ $ $ $ $
$ $ $ $ $
$ $ $ $
certify that all of the above information is true and correct and that all income
IIIIIJtecE~Ipt of Federal funds; that school officials may verify the information on the
subject me to prosecution under applicable State and Federal laws.
x o5*?-hO·Z'19i
Social Security Number*
NO. ____________ __ PRINTED NAME ------------------
STREET/APT. NO---------------CITY/STATEtZIP -------------DATE----
6 RACE: Please check the racial or ethnic identity of your child. You are not required to answer this question.
_ White, not Hispanic _ Black, not Hispanic _Hispanic Asian/Pacific Islander American Indian/Alaskan Native
*Privacy Act Statement: Section 9 of the National School Lunch act requires that, unless your child's food stamp or AFDC 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. Provision of a social security number is not mandatory, but 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 AFDC benefits, contactiilg 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.
FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 TWICE A MONTH X 2
Total household size: ------- Monthly income------ Food stamp ___ _ AFDC/ADC
Eligibility determination: Approved Free ___ Approved Reduced Price ___ Denied Te"l''rary until: ------- Until:-----
Reason for denial: Income too high___ Incomplete application___ Other-------------
Change in status: ---------------------------- Date withdrawn:-----
Reason
Signature of det.,.mining official:
Date
Date v"'Hication notice sent Response due from household: Second notice sent -------
Date:
Verifocation result: No change ___ Free to Reduced Price Free to Paid Reduced Price to Free Reduced Price to Paid
Until: ---------
Reason for eligibility change: Income ___ Household size Refused to cooperate ___ Charge In food llamp/AFDC __ Other ----------
Date 'notice of change' sent to parent/guardian: -----
Signature of verifying official:---------'----------------------- Date: _____ _
EXAMPLE APPLICATIONS
BEHRENS APPLICATION
PROBLEM: The Behrens application cannot
be approved because it does not have an
adult household member's signature and
social security number. The signature on the
application is that of Chris Behrens who is a
student at Lincoln High School.
SOLUTION: You have two options:
11
, 1. You may return the application to the
household for an adult household
member's signature and social security
number. You may not sign the application
for the household.
OR
2. You may deny the application. (See page
39 for further information on denying
applications.)
NOTE: The only exception to the adult signature requirement occurs when there are no adults
living in the household. In such cases a person under 21 years of age may sign the application.
However, the school official should ensure that the person signing the application is eligible to do
so.
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICATION FOR FREE AND REDUCED PRICE MEALS
To apply for free and reduced price meals, complete this application, sign your name and return the application to the school.
Call the school If you need help at # _______ , ...
1 Print STUDENT INFORMATION: 2 List the child's FOOD STAMP or AFDC case number, if any:
NA~£RAt.V 1Jtt rr~t GRADE NAME OF SCHOOL FOOD STAMP NUMBER OR AFDC NUMBER
j Sr. Ml~IIAEl- ~ ~11161/$1
3 FOSTER CHILD: Ust the child's monthly personal use income. Write "0" if the child has no personal use income: $ ___ _
4 HOUSEHOLD MEMBERS AND MONTHLY INCOME: If you gave a food stamp or AFDC case number for the child, skip to PART s.
Gross MONTHLY Earnings MONTHLY Welfare MONTHLY Any Other
NAMES OF HOUSEHOLD MEMBERS (Before Deductions) Payments, Child Payments from MONTHLY
Support, Alimony Pensions, Retirement, Income
Job 1 Job 2 Social Security
$ $ $ $ $
$ $ $ $ $
$ $ $ $ $
$ $ $ $ $
$ $ $ $ $
$ $ $ $ $
$ $ $ $
all of the above information is true and correct and that all income
funds; that school officials may verify the information on the
to prosecution under applicable State and Federal laws.
X,-a~7a--~~~~
Social Security Number*
6 RACE: Please check the racial or ethnic identity of your child. You are not required to answer this question.
_ White, not Hispanic _Black, not Hispanic _Hispanic Asian/Pacific Islander American Indian/Alaskan Native
*Privacy Act Statement: Section 9 of the National School Lunch act requires that, unless your child's food stamp or AFDC 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. Provision of a social security number is not mandatory, but 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 AFDC benefrts, 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.
FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 TWICE A MONTH X 2
Total household size: Monthly income Food stamp AFDC//IDC
Eligibility determination: Approved Free __ Approved Reduced Price __ Denied Terrporary until: ----- Until: ____ _ Until:-----
Reason for denial: Income too high __ Incomplete application__ Other-------------
Change in status: ----------------------------- Date withdrawn: ----
Reason Date
Signature of dete<mining official: Date:
Dale ve<ijication notice sent: Response due from household: Second notice sent -----
VerifiCation result: No change __ Free to Reduced Price Free to Psid Reduced Price to Free Reduced Price to Paid
Reason for eligibility change: Income __ Household size __ Refused to cooperate __ Change In food ltamp/AFDC __ Other -----------
Date "notice of change" sent to parent/guardian: -----
Signature of veritying official:----------------------------- Date: ___ _
EXAMPLE APPLICATIONS
SOLUTION: You have two options:
SMITH APPLICATION
PROBLEM: The Smith application cannot be
approved because it does not have an adult
household member's signature.
1. You may return the application to the household for an adult household member's signature.
You may not sign the application for the household.
OR
13
2. You may deny the application. (See page 39 for further information on denying applications.)
NOTE: The only exception to the adult signature
requirement occurs when there are no adults living in the
household. In such cases a person under 21 years of age
may sign the application. However, the school official
should ensure that the person signing the application is
eligible to do so.
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICATION FOR FREE AND REDUCED PRICE MEALS
To apply for free and reduced price meals, complete this application, sign your name and return the application to the school.
C~ll the school If you need help at # _______ _
1 Print STUDENT INFORMATION: 2 List the child's FOOD STAMP or AFDC case number, if any:
NAME GRADE NAME OF SCHOOL FOOD STAMP NUMBER OR AFDC NUMBER
!1ELV I~ JlJL.UJ S __Y:_ MA fJ..E if.EE
3 FOSTER CHILD: Ust the child's monthly personal use income. Write '0' if the child has no personal use income: $ ____ .
4 HOUSEHOLD MEMBERS AND MONTHLY INCOME: If you gave a food stamp or AFDC case number for the child, skip to PART s.
Gross MONTHLY Earnings MONTHLY Welfare MONTHLY
NAMES OF HOUSEHOLD MEMBERS
(Before :;~~!J-.-------===~:nlii:r":"----·;:::;~;:~~nnent.
Any Other
MONTHLY
Income
$ __ _ $ __ _
$ __ _ $ ___ _ $ __ _
$ ___ _ $ __ _ $ ___ _ $ __ _
$ __ _ $ __ _ $. ___ _ $ __ _
$. ___ _ $ __ _ $. ___ _ $ __ _
$. ___ _ $ __ _ $ ___ _ $ __ _
$ ___ _ $ __ _ $ ___ _ $ __ _
X 2..10 -;,--(, 1tft.
Social Security Number*
HOME TELEPHONE NO. --------WORK TELEPHONE NO. ------- PRINTED NAME ----------
STREET/APT. NO CITY/STATE/ZIP -------------DATE ----
6 RACE: Please check the racial or ethnic identity of your child. You are not required to answer this question.
_ White, not Hispanic _ Black, not Hispanic _Hispanic Asian/Pacific Islander American Indian/Alaskan Native
*Privacy Act Statement: Section 9 of the National School Lunch act requires that, unless your child's food stamp or AFDC 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. Provision of a social security number is not mandatory, but 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 AFDC 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.
FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 lWICE A MONTH X 2
Total household size: Monthly Income Food stamp AFOC/ADC __
8igibility determination: Approved Free __ Approved Reduced Price __ Denied Temporary until: Until: ___ _
Reason for denial: Income too high __ Incomplete application __ Other-------------
Change in status: Date withdrawn: -----
Reason
Signature of determining official:
Date verification notice sent ___ _ Response due from household: ___ _
Verification result No change __ Free to Reduced Prloe Free to Paid
Date
Date:
Second notice sent ___ _
Reduced Prica to Free Reduced Prica to Paid
Until: ____ _
Reason for eligibility change: Income __ Household size __ Refused to cooperate __ Change In food stamp/AFOC __ Other ----------
Date "notice of change• sent to perenl/guardian: -----
Signature of veritying official:----------------------------- Date: ___ _
EXAMPLE APPLICATIONS
SOLUTION: You have three options:
I. You may contact the household either by
phone or in writing to obtain the income
by person and source. As soon as you
obtain this information, enter it on the
income section of the application next to
the appropriate person's name and in the
appropriate column. Be sure to date and
initial any information you write on the
application.
OR
2. You may return the application to the
household. Instruct the household to
provide the missing information and
return it to the school as soon as possible.
OR
3. You may deny the application. (See page
39 for further information on denying
applications.)
JULIUS APPLICATION
PROBLEM: The Julius application cannot be
approved because it does not contain income by
person, and source.
"\.\I /
~
' ----
15
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICATION FOR FREE AND REDUCED PRICE MEALS
To apply for free and reduced price meals, complete this application, sign your name and
... Call the school If you need help at # ___ ----::
1 Print STUDENT INFORMATION: 2 List the child's
NAME GRADE NAME OF SCHOOL
HE" ATHER AA R.12Ji tt
3 FOSTER CHILD: Ust the child's monthly personal use income. Write "0"
4 HOUSEHOLD MEMBERS AND MONTHLY INCOME: If you gave
Gross MONTHLY Earnings
NAMES OF HOUSEHOLD MEMBERS (Before Deductions)
Job 1 Job 2
$ $
$ $
$ $
$ $
$ $
$ $
$ $
Payments, Child
Support, Alimony
$
$
$
$
$
$
$
Payments from
Pensions, Retirement,
Social Security
$
$
$
$
$
$
$
Any Other
MONTHLY
Income
$
$
$
$
$
$
$
5 SIGNATURE AND SOCIAL SECURITY NUMBER: I certify that all of the above information is true and correct and that all income
is reported. I understand that this information is being given for the receipt of Federal funds; that school officials may verify the information on the
application; an that deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws.
X ~ X.~~~--~=-~~ Adult Household Member Social Security Number*
HOME TELEPHONE NO. --------WORK TELEPHONE NO. ______ _ PRINTED NAME ----------
STREET/APT. NO---------------CITY/STATE/ZIP-------------DATE----
6 RACE: Please check the racial or ethnic identity of your child. You are not required to answer this question.
_ White, not Hispanic __ Black, not Hispanic __ Hispanic Asian/Pacific Islander American Indian/Alaskan Native
*Privacy Act Statement: Section 9 of the National School Lunch act requires that, unless your child's food stamp or AFDC 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. Provision of a social security number is not mandatory, but 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 AFDC 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.
FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 TWICE A MONTH X 2
Total household size: Monthly income Food stamp I>FDC/I>DC
8igibility determination: Approved Free __ Approved Reduced Price __ Denied Temporary until: ___ _ Until: ____ _ Until: ____ _
Reason for denial: Income too high __ Incomplete application__ Other-------------
Change in status: --------------- ------------­Date
withdrawn: ____ _
Reason Date
Signature of determining official: Date:
Date verification notice sent ___ _ Response due from household: ___ _ Second notice sent ___ _
Verification result: No change __ Free to Reduced Price Free to Paid Reduced Price to Free Reduced Price to Paid
Reason for eligibility change: Income __ Household size Refused to cooperate __ Change in food stamp//>FDC __ Other ----------
Date 'notice of change' sent to parent/guardian: -----
Signature of verifying official:----------------------------- Date: ___ _
EXAMPLE APPLICATIONS
SOLUTION: You have three options:
KARRIT APPLICATION
PROBLEM: The Karrit application cannot be
approved because it does not have an AFDC case
number. The household indicated that it receives
AFDC yet the space for the AFDC case number is
blank. No income or household size has been
provided.
17
1. You may contact the household either by phone or in
writing to obtain the AFDC case number. As soon
as you receive the case number, enter it in the
appropriate space on the application. Be sure to date
and initial any information you write on the
application.
OR
2. You may return the application to the household. Instruct the household to provide the
missing information and return it to the school as soon as possible.
OR
3. You may deny the application. (See page 39 for further information on denying applications.)
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICATION FOR FREE AND REDUCED PRICE MEALS
meals, complete this application, sign your name and return the application to the school.
school if you need help at # _______ _
1 List the child's FOOD STAMP or AFDC case number, if any:
OF SCHOOL FOOD STAMP NUMBER OR AFDC NUMBER
tz~tt~t>(l)
3
4
. Write "0" if the child has no personal use income: $ _____ .
If you gave a food stamp or AFDC case number for the child, skip to PART s.
Gross MONTHLY Earnings MONTHLY Welfare MONTHLY Any Other
NAMES OF HOUSEHOLD MEMBERS (Before Deductions) Payments, Child Payments from MONTHLY
Support, Alimony Pensions, Retirement, Income
Job 1 Job 2 Social Security
$ $ $ $ $
$ $ $ $ $
$ $ $ $ $
$ $ $ $ $
$ $ $ $ $
$ $ $ $ $
$ $ $ $ $
5 SIGNATURE AND SOCIAL SECURITY NUMBER: I certify that all of the above information is true and correct and that all income
is reported. I understand that this information is being given for the receipt of Federal funds; that school officials may verify the information on the
application; and that deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws.
X ~~ fi~bor X Social Security Numbe~
HOME TELEPHONE NO. --------WORK TELEPHONE NO. ------- PRINTED NAME ----------
STREET/APT. NO--------------- CllY/STATEtZIP --------------DATE ____ _
6 RACE: Please check the racial or ethnic identity of your child. You are not required to answer this question.
_ White, not Hispanic _ Black, not Hispanic _Hispanic Asian/Pacific Islander American Indian/Alaskan Native
*Privacy Act Statement: Section 9 of the National School Lunch act requires that, unless your child's food stamp or AFDC 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. Provision of a social security number is not mandatory, but 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 AFDC 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.
FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 TWICE A MONTH X 2
Total household size: Monthly income Food stamp /IFDC/ADC
Bigibility determination: Approved Free __ Approved Reduced Price __ Denied TefT1)0r&ry until: ----- Until:----- Until: ____ _
Reason for denial: Income too high__ Incomplete application__ Other-------------
Change in status: ---------------------------- Date withdrawn: ____ _
Reason
Signature of determining official:
Date verification notice sent ___ _ Response due from household: ___ _
VerifiCation result No change __ Free to Reduced Price Free to Paid
Date
Second notioe sent ----­Reduced
Price to Free
Date:
Reduced Price to Paid
Reason for eligibility change: Income __ Household size Refused to cooperate __ Change in food stamp//IFDC __ Other ----------
Date ' notice of change' sent to parent/guardian: ----­Signature
of verifying official:----------------------------- Date: ___ _
EXAMPLE APPLICATIONS
SOL UTI ON: You have three options:
19
HOUSTON APPLICATION
PROBLEM: The Houston application cannot
be approved because it does not provide the
name of the child for whom the application
was made. The name of the child is one of
the items required on a food stamp or AFDC
application.
1. You may contact the household either by phone or in writing to obtain the child's name. As
soon as you receive the name, enter it in the appropriate space on the application. Be sure to
date and initial any information you write on the application.
OR
2. You may return the application to the household.
Instruct the household to provide the missing
information and return it to the school as soon as
possible.
OR
3. You may deny the application. (See page 39 for
further information on denying applications.)
"'' J -
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICATION FOR FREE AND REDUCED PRICE MEAlS
To apply for free and reduc.ed price meals, complete this application, sign your name and return the appl~ation to the school.
Call the school If you need help at # _______ ,
1 Print STUDENT INFORMATION: 2 List the child's FOOD STAMP or AFDC
NAME GRADE NAME OF SCHOOL FOOD STAMP
HEN fl..Y LMS tiE~ I-+Af1N lflLk
3 FOSTER CHII:.D: Ust the child's monthly personal use income. Write ·o· if the child has no personal use
4 HOUSEHOLD MEMBERS AND MONTHLY INCOME: If you gave a food stamp or AFDC case number for the
MONTHLY
NAMES OF HOUSEHOLD MEMBERS
6HAR.ol'l LJ\~Srn~
:fOHN ~~~~re~
f+ENft'l LA~~r-rEr{ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
Any Other
MONTHLY
Income
$ _ _
$ _ _
$ _ _
$. __ _
$ _ _
$ _ _
$ _ _
5 SIGNATURE AND SOCIAL SECURITY NUMBER: I certify that all of the above information is true and correct and that all income
is reported. I understand that this information is being given for the receipt of Federal funds; that school officials may verify the information on the
application; and that deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws.
X 5/t.vwnv L~ X h6'1·l/~- 5~
Signature of Adult Household Member Social Security Number*
HOME TELEPHONE NO. -------- WORK TELEPHONE NO. ------­PRINTED
NAME ----------
STREET/APT. NO---------------CITY/STATE/ZIP------------- DATE----
6 RACE: Please check the racial or ethnic identity of your child. You are not required to answer this question.
_ White, not Hispanic _Black, not Hispanic _Hispanic Asian/Pacific Islander American Indian/Alaskan Native
*Privacy Act Statement: Section 9 of the National School Lunch act requires that, unless your child's food stamp or AFDC 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. Provision of a social security number is not mandatory, but 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 AFDC 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.
FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 TWICE A MONTH X 2
Total household size: Monthly income Food stamp AFOC/ADC
Blgibility determination: Approved Free __ Approved Reduced Price __ Denied Te"l''rary until: ___ _ Until: ___ _ Until:-----
Reason for denial: Income too high__ Incomplete application__ Other-------------
Change in status: --------------------------- Date withdrawn: ___ _
Reason Date
Signature of determining official: Date:
Date ver~ication notice sent: Response due from household: Second notice sent: ___ _
Verification result: No change __ Free to Reduced Price Free to Paid Reduced Price to Free Reduced Price to Paid
Reason for eligibility change: Income __ Household size __ Refused to cooperate __ Change in food stamp/AFOC __ Other ----------
Date 'notice of change' sent to parent/guardian: ___ _
Signature of veritying official:---------------------------- Date: ___ _
EXAMPLE APPLICATIONS 21
' .
LASSITER APPLICATION
PROBLEM: The Lassiter application has both an AFDC
case number and income information. The AFDC case
number makes the household eligible for free meals.
However, the income information makes the household
eligible for reduced price meals.
SOLUTION:
Whenever a household provides a food stamp
or AFDC case number and income
information, the application must be approved
based on the case number. Disregard the
income information. Therefore, the Lassiter
household is eligible for free meals.
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICAT.. ION FOR FREE AND REDUCED PRICE MEALS
To apply for free and reduced price meals, complete this application, sign your name and return the application to the school.
Call the school If you need help at '-------
1 Print STUDENT INFORMATION: 2 List the child's FOOD STAMP or AFDC case
NAME GRADE N~ OF SCHOOL WUx'l· eo'/DI£ ( Fo?IER. C1Hit,.~DJ'--------
3 FOSTER CHILD: Ust the child's monthly personal use income. Write •o• if the child has no personal use
4 HOUSEHOLD MEMBERS AND MONTHLY INCOME: If you gave a food stamp or AFDC case number
Gross MONTHLY Earnings MONTHLY Welfare MONTHLY Any Other
NAMES OF HOUSEHOLD MEMBERS (Before Deductions) Payments, Child Payments from MONTHLY
Support, Alimony Pensions, Retirement, Income
Job 1 Job 2 Social Security
$ $ $ $ $
$ $ $ $ $
$ $ $ $ $
$ $ $ $ $
$ $ $ $ $
$ $ $ $ $
$ $ $ $ $
5 SIGNATURE AND SOCIAL SECURITY NUMBER: I certify that all of the above information is true and correct and that all income
is reported. I understand that this information is being given for the receipt of Federal funds; that school officials may verify the information on the
application; an~srepresentation of the information may subject me to prosecution under applicable State and Federal laws.
X SlgnabJre of Adu~ ~r X f!3;.!;~~~
HOME TELEPHONE NO. --------WORK TELEPHONE NO. ------­PRINTED
NAME --------.,.--
STREET/APT. NO---------------CITY/STATE/ZIP------------- DATE-----
6 RACE: Please check the racial or ethnic identity of your child. You are not required to answer this question.
_ White, not Hispanic _Black, not Hispanic _Hispanic Asian/Pacific Islander American Indian/Alaskan Native
*Privacy Act Statement: Section 9 of the National School Lunch act requires that, unless your child's food stamp or AFDC 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. Provision of a social security number is not mandatory, but 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 AFDC 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.
FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 TWICE A MONTH X 2
Total household size: Monthly Income Food stamp I>FDC/I>DC __
BiglbHity determination: Approved Free __ Approved Reduced Prioe __ Denied Te"l'Clrary until: Until: ___ _
Reason for denial: Income too high__ Incomplete application__ Other-------------
Ctange in status: --------------------------- Date withdrawn: ___ _
Reason
Signature of determining official:
Date
Date verification notice sent Response due from household: Second notice sent ___ _
Date:
Verification result No change __ Free to Reduced Price Free to Paid Reduced Price to Free Reduced Price to Paid
Until:-----
Reason for eligibility change: Income __ Household size __ Refused to cooperate __ Change In food stamp/I>FDC __ Other----------
Date 'notice of change' sent to perenl/guardian: ___ _
Signature of veritying official:---------------------------- Date: ___ _
EXAMPLE APPLICATIONS 23
COYOTE APPLICATION
PROBLEM: The Coyote application cannot be approved
because it does not contain any income information.
Although this household is applying for meal benefits for
a foster child, the application must still contain the foster
child's income information.
SOLUTION: You have two options:
1. You may contact the household either by phone or in
writing to obtain the income information. Remember that
you want the income information for the foster child only.
If the foster child has no income, enter zero in the income
section. Do not leave the income section blank.
OR
2. You may deny the application. (See page 39 for further
information on denying applications.)
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICATION FOR FREE AND REDUCED PRICE MEALS
To apply for free and reduced price meals, complete this application, sign your name and return the application to the school.
... Call the school If you need help at #_ _· - -----
1 Print STUDENT INFORMATION: 2 List the child's FOOD STAMP or AFDC case number, if any:
NAME GRADE NAME OF SCHOOL FOOD STAMP NUMBER OR AFDC NUMBER
TbM eAftfEN,-fR 2- 0£~(.;MAN
3 FOSTER C.HILD: Ust the child's monthly personal use income. Write ·o• if the child has no personal use income: $ ___ _
4 HOUSEHOLD MEMBERS -AND MONTHLY INCOME: If you gave a food stamp or AFDC case number for the child, skip to PART 5.
NAMES OF HOUSEHOLD MEMBERS
$_.::..._ __
$-"""":----
$ ___ _
$ ___ _
$. ___ _
$ __ _
MONTHLY Welfare
Payments, Child
Support, Alimony
$
$
$
$
$
$
$
MONTHLY Any Other
Payments from MONTHLY
Pensions, Retirement, Income
Social Security
$ $
$ $
$ $
$ $
$ $
$ $
$ $
5 SIGNATURE AND SOCIAL SECURITY NUMBER: I certify that all of the above information is true and correct and that all income
is reported. I understand that this information is being given for the receipt of Federal funds; that school officials may verify the information on the
application; an that deliberate misr presentation of the information may subject me to prosecution under applicable State and Federal laws.
X X 5Jlf·~tt· 161,"
Social Security Number*
HOME TELEPHONE NO. --------WORK TELEPHONE NO. ______ _ PRINTED NAME ----------
STREET/APT. NO CITY/STATE/ZIP -------------DATE ___ _
6 RACE: Please check the racial or ethnic identity of your child. You are not required to answer this question.
_ White, not Hispanic _ Black, not Hispanic _Hispanic Asian/Pacific Islander American Indian/Alaskan Native
*Privacy Act Statement: Section 9 of the National School Lunch act requires that, unless your child's food stamp or AFDC 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. Provision of a social security number is not mandatory, but 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 AFDC 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.
FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 lWICE A MONTH X 2
Total household size: Monthly income Food stamp AFDC/ADC __
Eligibility determination: Approved Free __ Approved Reduced Price __ Denied Tefr4>0rary until: Until: ___ _
Reason for denial: Income too high __ Incomplete application __ Other -------------
Change In status: --------------------------- Date w~hdrawn: ___ _
Reason
Signature of determining official:
Date
Date verification notice sent: Response due from household: Second notice sent: ___ _
Date:
Veriflcation result: No change __ Free to Reduced Price Free to Paid Reduced Price to Free Reduced Price to Paid
Until: ____ _
Reason for eligibility change: Income __ Household size __ Refused to cooperate __ Change in food stamp/AFDC __ Other ----------
Date "notice of change• sent to parent/guardian: ___ _
Signature of veritying official:---------------------------- Date: ___ _
EXAMPLE APPLICATIONS 25
CARPENTER APPLICATION
PROBLEM: The Carpenter application shows that the
household has no income.
SOLUTION:
Whenever a household indicate~ that it has no income, the
application should be approved on a temporary basis for
forty-five days. After the forty-five days is over, the
household must be contacted to see if there has been any
change in their circumstances. If there has been no
change, the application should be approved for another
forty-five days. Continue to follow up with the household
every forty-five days until their income situation is
resolved, or they receive food stamp or AFDC benefits.
If there has been a change, the application should be
processed based on the new information. Write the new
information directly on the application in the space
provided. Remember to date and initial any information
you write on the application.
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICATION FOR FREE AND REDUCED PRICE MEALS
To apply for free and reduced price meals, complete this application, sign your name and retUrn the application to the school.
Call the school If you need help at # ______ _
1 Print STUDENT INFORMATION:
NAME
:fOSE Lo5 l!tlltfS
GRADE
JL
2 List the child's FOOD
NAME OF SCHOOL
MAR'(FIEL'D
3 FOSTER CHILD: Ust the child's monthly personal use income. Write "0" if the
4 HOUSEHOLD MEMBERS AND MONTHLY INCOME: If you gave a food stamp
Gross MONTHLY Earnings MONTHLY Welfare
NAMES OF HOUSEHOLD MEMBERS (Before Deductions) Payments, Child
Support, Alimony
Job 1 Job 2
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
MONTHLY
Payments from
Pensions, Retirement,
Social Security
$
$
$
$
$
$
$
Any Other
MONTHLY
Income
$
$
$
$
$
$
$
5 SIGNATURE AND SOCIAL SECURITY NUMBER: I certify that all of the above information is true and correct and that all income
is reported. I understand that this information is being given for the receipt of Federal funds; that school officials may verify the information on the
appli:tiori; and 1hat deHbio ;epr2!'~nnation may subject me to prosecution under ap~ica~: s;;d.F;,~ ~
~re 1 of AduH Household Member . Social Security Numbe~
HOME TELEPHONE NO. --------WORK TELEPHONE NO. ------- PRINTED NAME ----------
STREET/APT. NO CITY/STATE/ZIP --------------DATE ___ _
6 RACE: Please check the racial or ethnic identity of your child. You are not required to answer this question.
_ White, not Hispanic _ Black, not Hispanic _Hispanic Asian/Pacific Islander American Indian/Alaskan Native
*Privacy Act Statement: Section 9 of the National School Lunch act requires that, unless your child's food stamp or AFDC 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. Provision of a social security number is not mandatory, but 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 AFDC benefrts, 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.
FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 TWICE A MONTH X 2
Total household size: ------ Monthly income------ Food stamp ---­AFDC/
ADC
Eligibility determination: Approved Free __ Approved Reduced Price __ Denied Te"l''rary until: ---­Reason
for denial: income too high__ Incomplete application__ Other-------------
Until: ___ _ Until: ____ _
Change in status: ---------------------------- Date withdrawn:-----
Reason Date
Signature of determining official: Date:
Date verification notice sent ---- Response due from household: ---- Second notice sent ___ _
Verif1C8tion result: No change __ Free to Reduced Price Free to Paid Reduced Price to Free Reduced Price to Paid
Reason for eligibility change: income __ Household size Refused to cooperate __ Change In food stamp/AFDC __ Other ----------
Date •notice of change• sent to parent/guardian: ___ _
Signature of verifying official:----------------------------- Date: ___ _
EXAMPLE APPLICATIONS
LOS CRUCES
PROBLEM: The Los Cruces application does not have any income information listed. The
household has indicated that it has applied for AFDC benefits. If the household is eligible for
food stamp or AFDC benefits, it will be eligible for free school meals.
SOLUTION: Because the Los Cruces have not been approved for AFDC benefits, you cannot
approve the application based on AFDC information. Income information must be obtained
before the application can be approved. You have three options:
1. You may contact the Los Cruces household by phone or in
writing to obtain the household size and income
information. If the household gives you this information
on the phone or sends it to you, enter the information
directly on the application in the spaces provided. Process
the application based on this information. Remember to
date and initial all information you write on the
application.
OR
2. You may return the application to the household. Instruct
the household to provide the missing information and
return it to the school as soon as possible.
OR
3. You may deny the application. (See page 39 for further
information on denying applications.)
NOTE: If income information is received and this household is approved for reduced price
benefits or denied, you may want to follow up with the household in forty-five days. If the
household has been approved for food stamp or AFDC benefits, write the food stamp or AFDC
case number directly on the application and change the household eligibility category to free.
27
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICATION FOR FREE AND REDUCED PRICE MEALS
To apply for free and reduced price meals, complete this application, sign your name and return the application to the school.
Call the school If you need help at # ______ _
1 Print STUDENT INFORMATION: 2 List the child's FOOD STAMP or AFDC case number, if any:
NAME GRADE NAME OF SCHOOL FOOD STAMP NUMBER OR AFDC NUMBER
JAME~ fZ.l'I\Etl ~ '"LE.N VIE.W
3 FOSTER CHILD: Ust the child's monthly personal use income. Write "0" if the child has no personal use income: $ ___ _
4 HOUSEHOLD MEMBERS AND MONTHLY INCOME: If you gave a food stamp or AFDC case number for the child, skip to PART 5.
Gross MONTHLY Earnings MONTHLY Welfare MONTHLY Any Other
{Before Deductions) Payments, Child Payments from MONTHLY
Support, Alimony Pensions, Retirement, Income
Social Security
$ $ /p(J $ t6' $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
.$ $ $ $
$ $ $ $
I certify that all of the above information is true and correct and that all income
is reported. I is being given for the receipt of Federal funds; that school officials may verify the information on the
application; and that deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws.
x - &tt£v x3t3~~'*'iYl21e ~of Adult Household Member Social Security Number'*
HOME TELEPHONE NO. --------WORK TELEPHONE NO. ------- PRINTED NAME ----------
STREET/APT. NO---------------CITY/STATE/ZIP------------- DATE ___ _
6 RACE: Please check the racial or ethnic identity of your child. You are not required to answer this question.
_ White, not Hispanic _ Black, not Hispanic _Hispanic Asian/Pacific Islander American Indian/Alaskan Native
*Privacy Act Statement: Section 9 of the National School Lunch act requires that, unless your child's food stamp or AFDC 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. Provision of a social security number is not mandatory, but 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 AFDC 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.
FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 TWICE A MONTH X 2
Total household size: Monthly income Food stamp AFDC/I>DC
.Eligibility determination: Approved Free__ Approved Reduced Prlce __ Denied Te111>0rary until: ___ _ Until: ____ _ Until: ____ _
Reason for denial: Income too high __ Incomplete application__ Other-------------
Change in status: Date withdrawn: -----
Reason Date
Signature of determining official: Date:
Date vernication notice sent Response due from household: Second notice sent ___ _
Verification result No change __ Free to Reduced Price Free to Paid Reduced Price to Free Reduced Price to Paid
Reason for eligibility change: Income __ Household size Refused to cooperate __ Change in food stamp/AFDC __ Other ----------
Date "notice of change" sent to perent/guardian: -----
Signature of veritying official:----------------------------- Date: ___ _
EXAMPLE APPLICATIONS
SOLUTION: You have three options:
29
RITTER APPLICATION
PROBLEM: The Ritter application
cannot be approved because the names
of all household members are not
listed. For the application to be
considered complete, all household
members must be listed so that the size
of the household can be determined.
The household size is vital information
for determining eligibility.
I. You may contact the household either by phone or in writing to obtain the names of the
household members. As soon as you receive this information, enter the names in the
appropriate spaces on the application. Be sure that the income information is listed next to the
correct household member's name. The eligibility of the household cannot be determined until
this information is received.
OR
2. You may return the application to the
household. Instruct the household to
provide the missing information and
return it to the school as soon as
possible.
OR
3. You may deny the application. (See
page 39 for further information on denying applications.)
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICATION FOR FREE AND REDUCED PRICE MEALS
To apply for free and reduced price meals, complete this application, sign your name and return the application to the school.
Call the school If you need help at # _______ , ...
1 Print STUDENT INFORMATION: 2 List the child's FOOD STAMP or AFDC case number, if any:
NAME GRADE NAME OF SCHOOL FOOD STAMP NUMBER OR AFDC NUMBER
JoHN VAN& MLL.L.- e.REE.K.
3 FOSTER CHILD: Ust the child's monthly personal use income. Write •o• if the child has no personal use income: $ ___ ___,.
4 HOUSEHOLD MEMBERS AND MO'NTHLY INCOME: If you gave a food stamp or AFDC case number for the child, skip to PART s.
NAMES OF HOUSEHOLD MEMBERS
Gross MONTHLY Earnings
(Before Deductions)
MONTHLY Welfare
Payments, Child
Support, Alimony
MONTHLY Any Other
Payments from MONTHLY
Pensions, Retirement, Income
Social Security
$ $
$ $
$ $
$ $
$ $
$ $
$ $
5 SIGNATURE AND SOCIAL SECURITY NUMBER: I certify that all of the above information is true and correct and that all income
is reported. I understand that this information is being given for the receipt of Federal funds; that school officials may verify the information on the
application; and at delib~rate misr1e~sentation of the information may subject me to prosecution under applicable State and Federal laws.
x ~~ x2.4~-5~ .. 2tt~l
Signature of Adult Houseti Member Social Security Number*
HOME TELEPHONE NO. --------WORK TELEPHONE NO. ------­PRINTED
NAME ---------::::-#----f-~- 'l/s[4t STREET/APT. NO---------------CITY/STATE/ZIP-------------- DATE
6 RACE: Please check the racial or ethnic identity of your child. You are not required to answer this question.
_ White, not Hispanic _ Black, not Hispanic _Hispanic Asian/Pacific Islander American Indian/Alaskan Native
*Privacy Act Statement: Section 9 of the National School Lunch act requires that, unless your child's food stamp or AFDC 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. Provision of a social security number is not mandatory, but 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 AFDC benefits, contacting the State Employment Security Office to determine the
amount of benefrts 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.
FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 TWICE A MONTH X 2
Total household size: ------ Monthly income------ Food stamp ---­AFDC/
ADC
Bigibility determination: Approved Free __ Approved Reduced Price __ Denied Temporary until: ----­Reason
for denial: Income too high__ Incomplete application__ Other-------------
Until: ___ _
Change in status: ---------------------------- Date withdrawn: ___ _
Reason
Signature of detet'mlnlng official:
Date
Date vet'mcation notice sent Response due from household: Second notice sent -----
Date:
Verification result No change __ Free to Reduced Prioe Free to Paid Reduced Price to Free Reduced Price to Paid
Until:-----
Reason for eligibility change: Income __ Household size __ Refused to cooperate __ Chenge in food stamp/AFDC __ Other ----------
Date "notice of change" sent to parenVguardian: -----
Signature of verifying official:-----------------------------
Date: ___ _
EXAMPLE APPLICATIONS 31
YANG APPLICATION
PROBLEM: The Yang application shows that the household is
currently eligible for reduced price meals. However, the application
indicates that a reduction in income is expected in the next month.
This decrease in income would make the Yang household eligible for
free meals.
SOLUTION:
When a family notes on an application that it is expecting a
change in income or family size, its application must be
approved for the category for which they are currently
eligible. Based on the current income, the household should
be temporarily approved for reduced price benefits.
Follow up with the household immediately after the date that
the income change is expected. If no date is given, follow-up
in forty-five days from the date of application. If the income
has changed, get the new income information and re-process
the application based on this information. Be sure to initial
and date any information you write on the application.
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICATION FOR FREE AND REDUCED PRICE MEAlS
To apply for free and reduced price meals, complete this application, sign your name and return the application to the school.
Call the school If you need help at # ______ _
1 Print STUDENT INFORMATION: 2 List the child's FOOD STAMP or AFDC case number, if any:
NAME GRADE NAME OF SCHOOL FOOD STAMP NUMBER OR AFDC NUMBER
fJ~ ~IIAf~N 5 &A~VNE({
3 FOSTER CHILD: Ust the child's monthly personal use income. Write •o• if the child has no personal use income: $ ____ .
4 HOUSEHOLD MEMBERS AND MONTHLY INCOME: If you gave a food stamp or AFDC case number for the child, skip to PART s.
Gross MONTHLY Earnings MONTHLY Welfare MONTHLY Any Other
NAMES OF HOUSEHOLD MEMBERS (Before Deductions) Payments, Child Payments from MONTHLY
Support, Alimony Pensions, Retirement, Income
Job 1 Job 2 Social Security
l'i>oo $ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $ $
$ $ $ $ $
5 SIGNATURE AND SOCIAL SECURITY NUMBER: I certify that all of the above information is true and correct and that all income
is reported. I understand that this information is being given for the receipt of Federal funds; that school officials may verify the information on the
application; and that deliberate ~prqsentation of the information may subject me to prosecution under applicable State and Federal laws.
X ~ult~ X~c~~~~U:!?.~
HOME TELEPHONE NO. --------WORK TELEPHONE NO. ------­PRINTED
NAME ----------
STREET/APT. NO---------------CITY/STATE/ZIP------------- DATE----
6 RACE: Please check the racial or ethnic identity of your child. You are not required to answer this question.
_ White, not Hispanic _ Black, not Hispanic _Hispanic Asian/Pacific Islander American Indian/Alaskan Native
*Privacy Act Statement: Section 9 of the National School Lunch act requires that, unless your child's food stamp or AFDC 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. Provision of a social security number is not mandatory, but 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 AFDC 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.
FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 TWICE A MONTH X 2
Total household size: Monthly Income Food stamp AFOC/MJC
8iglbility determination: Approved Free __ Approved Reduced Price __ Denied Temporary until: ___ _ Until: ___ _ Until: -----
Reason for denial: Income too high __ Incomplete application __ Other -------------
c~~e~status: ----------------------------
Date withdrawn: ___ _
Reason Date
Signature of determlni~ official: Date:
Date verification notice sent Response due from household: Second notice sent ___ _
Verilfication result: No c~e __ Free to Reduced Price Free to Paid Reduced Price to Free Reduced Price to Paid
Reason for eligibility c:ha~e: Income __ Household size Refused to cooperate __ C~~e In food stamp/AFOC __ Other -----------
Dille "notice of c:ha~e· sent to parent/guardian: ___ _
Signature of veritylng official:----------------------------
Date: ___ _
EXAMPLE APPLICATIONS
SOLUTION:
The Simpson application must be processed
based on the present household size. Based
on the household's current circumstances,
the household must be denied benefits at this
time.
You may follow up with the household in
forty-five days to determine whether the
household size has increased. If so, get the
new information and re-process the
application based on this information. Be
sure to initial and date any information you
write on the application.
NOTE: This procedure should be followed
. , ;
SIMPSON APPLICATION
PROBLEM: The Simpson application
indicates that the household size will change
soon because Mrs. Simpson is expecting a
baby.
any time a change in household size is expected. This includes a decrease in household size.
33
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
..
APPLICATION FOR FREE AND REDUCED PRICE MEALS
To apply for free and reduced price meals, complete this application, sign your name and return the application to the school.
Call the school If you need help at # ______ _
1 Print STUDENT iNFORMATION: 2 List the child's FOOD STAMP or AFDC case number, if any:
NAME GRADE NAME OF SCHOOL FOOD STAMP NUMBER OR AFDC NUMBER
FftEO WH-t1'f'LE. ll fle.\U.'{ ~ l6H
3 FOSTER CHILD: Ust the child's monthly personal use income. Write •o• if the child has no personal use income: $ -----
4 HOUSEHOLD MEMBERS AND MONTHLY INCOME: If you gave a food stamp or AFDC case number for the child, skip to PART s.
MONTHLY Welfare MONTHLY Any Other
NAMES OF HOUSEHOLD MEMBERS Payments, Child Payments from MONTHLY
Support, Alimony Pensions, Retirement, Income
Social Security
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $ $ $
$ $ $ $ $
$ $ $ $ $
5 SIGNATURE AND SOCIAL SECURITY NUMBER: I certify that all of the above information is true and correct and that all income
is reported. I understand that this information is being given for the receipt of Federal funds; that school officials may verify the information on the
application; and that deliberate mis epresentation of the information may subject me to prosecution under applicable State and Federal laws.
X X ;t , .. ll~ _. q z I =J-Soclal
Security Number*
HOME TELEPHONE NO. ________ WORK TELEPHONE NO. ------- PRINTED NAME ----------
STREET/APT. NO CITY/STATE/ZIP --------------DATE----
6 RACE: Please check the racial or ethnic identity of your child. You are not required to answer this question.
_ White, not Hispanic _ Black, not Hispanic _Hispanic Asian/Pacific Islander American Indian/Alaskan Native
*Privacy Act Statement: Section 9 of the National School Lunch act requires that, unless your child's food stamp or AFDC 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. Provision of a social security number is not mandatory, but 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 AFDC benefits, contacting the State Employment Security Office to determine the
amount of benefrts 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.
FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 TWICE A MONTH X 2
Total household size: Monthly income Food &tamp AFDC/MJC
Biglbility determination: Approved Free __ Approved Reduced Price __ Denied Te"l>>rary until: ---- Until: ___ _ Until:-----
Reason for denial: Income too high __ Incomplete application __ Other -------------
Chenge in status: --------------------------- Date withdrawn: ___ _
Reason
Signature of determining official:
Date verification notice sent Response due 1rom household: ----
Verifocatlon result: No change __ Free to Reduced Price Free to Paid
Date
Date:
Second notice sent ___ _
Reduced Price to Free Reduced Price to Paid
Reason for eligibility change: Income __ Household size __ Refused to cooperate __ Chenge In food &tamp/AFDC __ Other ----------
Date "notice of change• sent to perent/guardian: ___ _
Signature of veritying official:---------------------------- Date: ___ _
EXAMPLE-APPLICATIONS
WHIPPLE APPLICATION
PROBLEM: The Whipple application has income
reported in both weekly and monthly time periods. The
income needs to be converted into one time period
before it can be processed.
SOLUTION:
In order to process the Whipple application, the income
must be converted into a common time period. For
example, to convert the weekly income to monthly:
1) Multiply the weekly income by 4.33*;
$200.00 X 4.33 = $866.00/month
2) Add the two figures together;
$700.00 + $866.00 = $1566.00 total monthly income
Write the total monthly income directly on the application. Be sure to initial and date any
information you write on the application.
35
Now the application can be processed based on the total monthly income. The Whipple household
will qualify for reduced price meals.
* For more information on income conversion, see page 47.
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPLICATION FOR FREE AND REDUCED PRICE MEALS
To apply for free and reduced price meals, complete this application, sign your name and return the application to the school.
Call the school If you need help at #. _____ _
1 Print STUDENT INFORMATION: 2 List the child's FOOD STAMP or AFDC case number, if any:
NC~E.ft~ L tERGV~otJ GRADE NAME OF SCHOOL FOOD STAMP NUMBER OR AFDC NUMBER
JL UAf..:t .. £
3 FOSTER CHILD: Ust the child's monthly personal use income. Write "0" if the child has no personal use income: $ ___ _
4 HOUSEHOLD MEMBERS AND MONTHLY INCOME: If you gave a food stamp or AFDC case number for the child, skip to PARTs.
NAMES OF HOUSEHOLD MEMBERS
Job 2
5DO 9Z::JWIJIJTHL'{
/5"0 WE i.K.l-'[
$. ___ _ $ __ _
$. ___ _ $ __ _
$ ___ _ $ __ _
$ __ _
$ ___ _
$ ___ _
MONTHLY Any Other
Payments from MONTHLY
Pensions, Retirement, Income
Social Security
$ $
$ $
$ $
$ $
$ $
$ $
$ $
5 SIGNATURE AND SOCIAL SECURITY NUMBER: I certify that all of the above information is true and correct and that all income
is reported. I understand that this information is being given for the receipt of Federal funds; that school officials may verify the information on the
application; and that deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws.
X P;o}J ~~ X ft~5~~t~l/~fJI/-
Signature ofAdHOUSet10idMimber Social Security Number*
HOME TELEPHONE NO. ________ WORK TELEPHONE NO. ______ _ PRINTED NAME -----------
STREET/APT. NO---------------CITY/STATE/ZIP-------------- DATE ____ _
6 RACE: Please check the racial or ethnic identity of your child. You are not required to answer this question.
_ White, not Hispanic _Black, not Hispanic _Hispanic Asian/Pacific Islander American Indian/Alaskan Native
*Privacy Act Statement: Section 9 of the National School Lunch act requires that, unless your child's food stamp or AFDC 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. Provision of a social security number is not mandatory, but 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 AFDC 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.
FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 TWICE A MONTH X 2
Total household size: ------ Monthly income------ Food stamp __ _ AFDC/ADC
Eligibility determination: Approved Free __ Approved Reduced Price __ Denied Temporary until: ___ _ Until: ___ _ Until: -----
Reason for denial: Income too high__ Incomplete application__ Other-------------
Change in status: --------------------------- Date w~hdrawn: ___ _
Reason Date
Signature of determining official: Date:
Date verffication notice sent Response due from household: Second notice sent ___ _
Verification result: No change __ Free to Reduced Price Free to Paid Reduced Price to Free Reduced Price to Paid
Reason for eligibility change: Income __ Household size __ Refused to cooperate __ Change in food stamp/AFDC __ Other ----------
Date "notice of change' sent to parent/guardian: ___ _
Signature of verifying official:---------------------------- Date: ___ _
',;
EXAMPLE APPLICATIONS 37
FERGUSSON APPLICATION
PROBLEM: The Fergusson application shows that income is received
bi-monthly (twice a month) and weekly. The application cannot be
processed until the income is converted into one common time period.
SOLUTION:
In order to process the Fergusson application, the income needs to be
converted into a common time period. For example, to convert the
income into a monthly figure:
1) Multiply the bi-monthly (twice a month) income by two;
$500.00 X 2 = $1,000.00
2) Multiply the weekly income by 4.33*;
$150.00 X 4.33 = $649.50
3) Add the two figures together;
$1,000.00 + $649.50 = $1,649.50
Write the total monthly income directly on the application. Be sure to initial and date any
information you write on the application.
Now the application can be processed based on the total monthly income. The Fergusson
household will qualify for reduced price meals.
* For more information on income conversion, see page 47.
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
DENYING APPLICATIONS 39
DENYING APPLICATIONS
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
DENYING APPLICATIONS 41
You may deny an application when:
- An application submitted by a household does not contain all of the
required information.
The household may provide missing information after you deny an
application. You must then re-process the application based on the
new information.
You must deny an application when:
- An application submitted by a household does not contain all of the
required information and you have been unsuccessful in obtaining the
information from the household;
- The household's income is above the limits of the income eligibility
guidelines for free and reduced price meals.
When you deny an application, you must promptly notify the household.
This notification MUST BE IN WRITING. The notice sent to the
household must provide the following:
- The reason for the denial of benefits, e.g., the income is too high;
- Notification of the right to appeal;
- Instructions on how to appeal; and,
- A reminder that the household may reapply for benefits at any time
during the school year.
Appendix A of this guide provides an example of a notification letter. Please
note notification letters must be sent to households that have been denied
benefits.
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
42 APPENDICES
APPENDICES
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPENDICES 43
APPENDIX A
SAMPLE NOTIFICATION LETTER
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
44 APPENDICES
APPENDIX A
NOTIFICATION LETTER FOR SCHOOL MEALS
~u .
--------------------------------~·
Your application for free and reduced price meals for your child(ren) has been:
______ Approved for free meals.
Approved for reduced price meals at cents for lunch and
------ cents for breakfast. ------
------ Denied for the following reason(s):
_______ Income over the allowable amount.
_______ Incomplete application. The following information is
missing: ----------------------------------
_______ Other: ________________________________ _
If you do not agree with the decision, you may discuss it with the school official and you have a
right to a fair hearing. This can be done by calling or writing the following official:
Name:
Address:
Phone:
If your child is approved for meal benefits, you must tell the school when your household income
increases by more than $50 per month ($600 per year) or when household size decreases. If your
child is approved for meal benefits based on eligibility for food stamps or AFDC, you must tell the
school when you no longer receive food stamps or AFDC for your child.
You may reapply for benefits at any time during the school year. If you are not eligible now but
have a decrease in income or an increase in household size, or qualify for food stamp or AFDC
benefits, you may fill out another application at that time.
Sincerely,
(NAME) (TITLE) (DATE)
In the operation of child feeding programs, no child will be discriminated against because of race,
sex, color, national origin, age or handicap. If you believe you have been discriminated against,
write immediately to the Secretary of Agriculture, Washington D.C. 20250. ·
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
~ · .
APPENDICES 45
APPENDIXB
INCOME ELIGIBILITY GUIDELINES
The income eligibility guidelines in Appendix B of this booklet are designed for use with this
booklet only. Do not use these income eligibility guidelines to process applications. When
processing your applications, use the current guidelines which are forwarded to you from
the State.
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
...
46
FAMILY SIZE
1
2
3
4
5
6
7
8
For each additional
family member add:
1
2
3
4
5
6
7
8
For each additional
family member add:
...
INCOME ELIGIBILI'IY GUIDELINES
FREE MEALS
WEEKLY INCOME MONTHLY INCOME
166 718
222 962
~$IP11~ ~11 Lr 448 '
505
561
+57
1,942
2,187
2,431
+245
REDUCED PRICE MEALS
236 1,021
316 1,369
397 1 '718
477 2,066
~~IP11~ ~11Lr
718 3,112 .
798 3,460
+81 +349
APPENDICES
APPENDIX B
YEARLY INCOME
8,606
11,544
14,482
17,420
20,358
23,296
26,234
29,172
+2,938
12,247
16,428
20,609
24,790
28,971
33,152
37,333
41,514
+4,181
The income eligibility guidelines in Appendix B of this booklet are designed for use with this
booklet only. Do not use these income eligibility guidelines to process applications. When
processing your applications, use the current guidelines which are forwarded to you from
the State.
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
APPENDICES
APPENDIX C
INCOME CONVERSION
PROCESSING FREE AND REDUCED PRICE APPLICATIONS
' ·"'
47
MWRO 1991
48
MONTHLY INCOME
CONVERSION METHOD
APPENDICES
APPENDIX C
Weekly Income X 4.33 = Monthly Income
Income Every 2 Weeks X 2.15· = Monthly Income
Income Twice A Month X 2 = Monthly Income
Annual Income + 12 = Monthly Income
PROCESSING FREE AND REDUCED PRICE APPLICATIONS MWRO 1991
~ · ' *U.S. G.P.0.:1991-544- 912:32572