2018-2019 Application for Free and Reduced Price Meals New Applicant Previous Applicant Complete one application per household. Please use a pen (not a pencil). Write name of or in If a student, child’s school, “not write in the grade Age school” Child’s Name Homeless, Foster Migrant, Child Runaway If you answered NO > Complete STEPS 3 and 4. If YES > Write your 9-digit SNAP, TANF, or FDPIR case number here then go to STEP 4 Write only one case number in this space. (Do not complete STEP 3) Case Number: Child Income Sometimes children in the household earn or receive income. Please include the TOTAL income received by all children listed in STEP 1 here. 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 (b e f o r e t ax xes) for each source in whole dollars only. If they do not receive income from any source, write If you enter or leave any fields blank, you are certifying (promising) that there is no income to report. ‘0’. ‘0’ Check if no SSN Street Address (if available) Apt # City State Zip Daytime Phone and Email (optional) Printed name of adult completing the form Signature of adult completing the form today’s date
2018-2019 Application for Free and Reduced Price Meals Complete one application per household. Please use a pen (not a pencil). New Applicant Previous Applicant Child’s Name Age Write name of child’s school, or “not in school” If a student, write in the grade Homeless, Foster Migrant, Child Runaway If you answered NO > Complete STEPS 3 and 4. If YES > Write your 9-digit SNAP, TANF, or FDPIR case number here then go to STEP 4 (Do not complete STEP 3) Case Number: Write only one case number in this space. Child Income Sometimes children in the household earn or receive income. Please include the TOTAL income received by all children listed in STEP 1 here. 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 (b e f o r e t ax xes) for each source in whole dollars only. If they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report. Check if no SSN Street Address (if available) Apt # City State Zip Daytime Phone and Email (optional) Printed name of adult completing the form Signature of adult completing the form today’s date