E) Report income from F) Report total household size. Enter the total number of household G) Provide the last four digits of your Social Security pensions/retirement/all other income. members in the field “Total Household Members (Children and Adults).” Number. An adult household member must enter the last Report all income that applies in the This number MUST be equal to the number of household members listed four digits of their Social Security Number in the space “Pensions/Retirement/All Other Income” in STEP 1 and STEP 3. If there are any members of your household that you provided. You are eligible to apply for benefits even if you field on the application. have not listed on the application, go back and add them. It is very do not have a Social Security Number. If no adult important to list all household members, as the size of your household household members have a Social Security Number, leave affects your eligibility for free and reduced price meals. this space blank and mark the box to the right labeled “Check if no SSN.” STEP 4: CONTACT INFORMATION AND ADULT SIGNATURE All applications must be signed by an adult member of the household. By signing the application, that household member is promising that all information has been truthfully and completely reported. Before completing this section, please also make sure you have read the privacy and civil rights statements on the back of the application. A) Provide your contact information. B) Print and sign your name and write today’s date. Print the name of the C) Mail D) Share children’s racial and ethnic Write your current address in the fields adult signing the application and that person signs in the box “Signature of Completed identities (optional). On the back of the provided if this information is available. If adult.” Form to: application, we ask you to share you have no permanent address, this Bloomfield information about your children’s race does not make your children ineligible for Food Service and ethnicity. This field is optional and free or reduced price school meals. 390 Park Ave. does not affect your children’s eligibility Sharing a phone number, email address, Bloomfield CT, for free or reduced price school meals. or both is optional, but helps us reach you 06002 quickly if we need to contact you.
E) Report income from pensions/retirement/all other income. Report all income that applies in the “Pensions/Retirement/All Other Income” field on the application. F) Report total household size. Enter the total number of household members in the field “Total Household Members (Children and Adults).” This number MUST be equal to the number of household members listed in STEP 1 and STEP 3. If there are any members of your household that you have not listed on the application, go back and add them. It is very important to list all household members, as the size of your household affects your eligibility for free and reduced price meals. G) Provide the last four digits of your Social Security Number. An adult household member must enter the last four digits of their Social Security Number in the space provided. You are eligible to apply for benefits even if you do not have a Social Security Number. If no adult household members have a Social Security Number, leave this space blank and mark the box to the right labeled “Check if no SSN.” STEP 4: CONTACT INFORMATION AND ADULT SIGNATURE All applications must be signed by an adult member of the household. By signing the application, that household member is promising that all information has been truthfully and completely reported. Before completing this section, please also make sure you have read the privacy and civil rights statements on the back of the application. A) Provide your contact information. Write your current address in the fields provided if this information is available. If you have no permanent address, this does not make your children ineligible for free or reduced price school meals. Sharing a phone number, email address, or both is optional, but helps us reach you quickly if we need to contact you. B) Print and sign your name and write today’s date. Print the name of the adult signing the application and that person signs in the box “Signature of adult.” C) Mail Completed Form to: Bloomfield Food Service 390 Park Ave. Bloomfield CT, 06002 D) Share children’s racial and ethnic identities (optional). On the back of the application, we ask you to share information about your children’s race and ethnicity. This field is optional and does not affect your children’s eligibility for free or reduced price school meals.
FamilyApp4%202017%20-%202018.docx