Application for School Meals

2020-2021 Household Application for Free and Reduced Price School Meals

Step 1:

List ALL infants, children, and students up to and including grade 12 who are Household Members. (*Definition of Household Member: “Anyone who is living with you and shares income and expenses, even if not related.”)

Step 2:

If you answered NO > Complete STEP 3. If you answered YES > Write a case number here, then go to STEP 4 (Do not complete STEP 3)

Step 3:

Report Income for ALL Household Members

Dollar Amount: $0
Sometimes children in the household earn income. Please include the TOTAL income earned by all infants, children, and students up to and including grade 12 listed in STEP 1 here.

Adult Income

All Adult Household Members (including yourself) List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total gross income (before taxes) for each source in whole dollars only (no cents). If they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.

(Children and Adults)—REQUIRED
Last Four Digits of Social Security Number (SSN) of Primary Wage Earner or Other Adult Household Member—REQUIRED or Check box if no SSN

Step 4: Contact Information & Adult Signature

“I CERTIFY (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted under applicable state and federal laws.”

(If applicable)
(optional)
Today's Date

Optional

We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children’s eligibility for free or reduced price meals.

Please check one
Please check one or more
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  • info@sanjosecyber.org