2018-2019 Household Application for Free and Reduced Price School Meals Complete one application per household. Please use a pen (not a pencil). TO APPLY ON LINE: https://www.lunchapp.com/ Student? Child’s First Name MI Child’s Last Name Migrant, Yes No Runaway Foster Child If NO > Go to STEP 3. If YES > Write a case number here then go to STEP 4 (Do not complete STEP 3) Write only one case number in this space. $ A. Income Sometimes children in the household earn or receive income. Please include the TOTAL income received by all Household Members listed in STEP 1 here. Child How income B. 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 (no cents) only. If they do not receive income from any source, write If you enter or leave any blank, you are certifying (promising) that there is no income to report. ‘0’. ‘0’ Public Assistance/ Earnings from Child All Other Income Work Name of Adult Household Members (First and Last) Support/Alimony How often? How often? How often? $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Last Four Digits of Social Security Number (SSN) of Total Household Members (Children and Adults) Primary Wage Earner or Other Adult Household Member Check if no SSN 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 “I false information, my children may lose meal and I may be prosecuted under applicable State and Federal laws.” Street Address (if available) Apt # City State Zip Daytime Phone and Email (optional) Printed name of adult signing the form Signature of adult Today’s date
2018-2019 Household Application for Free and Reduced Price School Meals Complete one application per household. Please use a pen (not a pencil). TO APPLY ON LINE: https://www.lunchapp.com/ Child’s First Name MI Child’s Last Name Student? Yes No Foster Child Migrant, Runaway If NO > Go to STEP 3. If YES > Write a case number here then go to STEP 4 (Do not complete STEP 3) Write only one case number in this space. A. Income Sometimes children in the household earn or receive income. Please include the TOTAL income received by all Household Members listed in STEP 1 here. B. All Adult Household Members (including yourself) Child income $ How 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 (no cents) only. If they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any blank, you are certifying (promising) that there is no income to report. Name of Adult Household Members (First and Last) Earnings from Work $ How often? Public Assistance/ Child Support/Alimony $ How often? All Other Income $ How often? $ $ $ $ $ $ $ $ $ $ $ $ Total Household Members (Children and Adults) Last Four Digits of Social Security Number (SSN) of Primary Wage Earner or Other Adult Household Member Check if no SSN “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 and I may be prosecuted under applicable State and Federal laws.” Street Address (if available) Apt # City State Zip Daytime Phone and Email (optional) Printed name of adult signing the form Signature of adult Today’s date
18-19%20%20Free%20and%20Reduced%20Application.docx