Claiming Categories OSPI Name of Eligible Adult in Attendance Age of Type of Case Number/ Verification Source Eligibility Begin Use Only Reduced- Above- and Last Name—Alphabetize by Last Name) Person Assistance Date/ End Date Free NO. Price Scale 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 Scale Free Price Total = Subtotal (this page) Subtotal (page 1) = Grand Total =
NO. Name of Eligible Adult in Attendance and Last Name—Alphabetize by Last Name) Age of Person Type of Assistance Case Number/ Verification Source Eligibility Begin Date/ End Date Claiming Categories OSPI Use Only Free Reduced- Price Above- Scale 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 Free Price Scale Total Subtotal (this page) = Subtotal (page 1) = Grand Total =