Household Determination: Convert to Annual if Multiple Signature of Foster Student(s):________________________________________________ Frequencies: Confirming Official: Food Stamp/TAFI/FDPIR Weekly x52, Every 2 Weeks x26, *Must be a different individual than the Determining Official Income: Total Income $____________ Frequency___________ # in Household______ Twice Monthly x24, Monthly x12 Date 1st Date 2nd Notification Sent: Notification Sent: Approved: Denied: Date Notice Sent: Results: Free Meals Income over Allowed No Change Free to Reduced Reduced to Free Reduced-Price Meals Incomplete/Missing Ineligible Reason: __________________________________________ – Withdrawal Date:__________ Other _________________ Signature of Date Determined: Signature of Date: Determining Official: Verifying Official: *Must be a different individual than the Confirming Official *Can be same as Determining Official
Household Determination: Foster Student(s):________________________________________________ Food Stamp/TAFI/FDPIR Income: Total Income $____________ Frequency___________ # in Household______ Convert to Annual if Multiple Frequencies: Weekly x52, Every 2 Weeks x26, Twice Monthly x24, Monthly x12 Signature of Confirming Official: *Must be a different individual than the Determining Official Date 1st Notification Sent: Date 2nd Notification Sent: Approved: Free Meals Reduced-Price Meals Withdrawal Date:__________ Denied: Income over Allowed Incomplete/Missing Other _________________ Date Notice Sent: Results: No Change Free to Reduced Reduced to Free Ineligible – Reason: __________________________________________ Signature of Determining Official: *Must be a different individual than the Confirming Official Date Determined: Signature of Verifying Official: *Can be same as Determining Official Date:
2017-2018_free_and_reduced_price_application_english.docx