Application for School Meals

Step 1:

Number of Children in Household *

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.”)

First Child's Name *

First

Middle

Last

First Child's Grade *

School First Child Attends *

Check all that apply:

Foster Child
Homeless, Migrant, Runaway
Head Start

Second Child's Name *

First

Middle

Last

Second Child's Grade *

School Second Child Attends *

Check all that apply:

Foster Child
Homeless, Migrant, Runaway
Head Start

Third Child's Name *

First

Middle

Last

Third Child's Grade *

School Third Child Attends *

Check all that apply:

Foster Child
Homeless, Migrant, Runaway
Head Start

Fourth Child's Name *

First

Middle

Last

Fourth Child's Grade *

School Fourth Child Attends *

Check all that apply:

Foster Child
Homeless, Migrant, Runaway
Head Start

Step 2:

Do any Household Members (including you) currently participate in any of the following assistance programs: FoodShare, W-2 Cash Benefits, or FDPIR *

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)

Case Number *

Write only one case number in this space

Program Name *

Medicaid and Badger Care do not qualify

Step 3:

Report Income for ALL Household Members

Child Income

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.

How Often

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.

Number of Adult(s) in Household *

Full Name *

Earnings from Work

Dollar Amount: $0

How Often

Public Assistance/Alimony/SSI/VA Benefits

Dollar Amount: $0

How Often

Pensions/Retirement/ Social Security/Other Income

Dollar Amount: $0

How Often

Seasonal Workers, and others with fluctuating income, project the annual income and report here.

Dollar Amount: $0

Adult 2: Full Name *

Earnings from Work

Dollar Amount: $0

How Often

Public Assistance/Alimony/SSI/VA Benefits

Dollar Amount: $0

How Often

Pensions/Retirement/ Social Security/Other Income

Dollar Amount: $0

How Often

Seasonal Workers, and others with fluctuating income, project the annual income and report here.

Dollar Amount: $0

Adult 3: Full Name *

Earnings from Work

Dollar Amount: $0

How Often

Public Assistance/Alimony/SSI/VA Benefits

Dollar Amount: $0

How Often

Pensions/Retirement/ Social Security/Other Income

Dollar Amount: $0

How Often

Seasonal Workers, and others with fluctuating income, project the annual income and report here.

Dollar Amount: $0

Adult 4: Full Name *

Earnings from Work

Dollar Amount: $0

How Often

Public Assistance/Alimony/SSI/VA Benefits

Dollar Amount: $0

How Often

Pensions/Retirement/ Social Security/Other Income

Dollar Amount: $0

How Often

Seasonal Workers, and others with fluctuating income, project the annual income and report here.

Dollar Amount: $0

Total Household Members *

(Children and Adults)—REQUIRED

Last 4 Digits of SS# *

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

Check Box if no SS#

No SS#

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.”

Address

Address Line 1

Address Line 2

City

State

Zip Code

(If applicable)

Phone *

Email

(optional)

Signature *

Date *

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.

Ethnicity

Please check one

Race

Please check one or more

Application for School Meals

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

Step 1:

Step 2:

Step 3:

Adult Income

Step 4: Contact Information & Adult Signature

Optional