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FREE AND REDUCED PRICE SCHOOL MEALS FAMILY APPLICATION Part 1. Children in School use a separate ap lication for each foster child Names of all children in school Food Stamp or TANF case#(if any). Skip to Part (First,Middle Initial,Last School Name Grade 5 if you list a Food Stamp or TANF case# Part 2. If the child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your school, homeless liaison, migrant coordinator at phone #508-539-1500. Homeless ❑ Migrant ❑ Runaway ❑ Part 3. Foster Child If this application is for a child who is the legal responsibility of a welfare agency or court,check this box❑ and then list the amount of the child's personal use monthly income: $ . Skip to Part 5. Part 4. Total Household Gross Income—You must tell us how much and how often 2.Gross income and how often it was received 3. 1.Name From le: $100/monthl $100/twice a month $100%ve other week $100/weekI Check (List everyone Earnings from work Welfare,child support, Pensions,retirement, if NO in household) before deductions alimon Social Securit All Other Income income (example) $200/weekly 5150/weekly 5100/monthly 5 / ❑ Jane Smith $ $ $ $ ❑ $ $ $ $ ❑ $ $ $ $ ❑ ❑ Part 5. Signature and Social Security Number jAduliz must sign An adult household member must sign the application.If Part 4 is completed,the adult signing the form must also list his or her Social Security Number or mark the"I do not have a Social Security Number"box. (See Privacy Act Statement on the back of this page.) I certify(promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds based on the information Igive.I understand that school officials may verify(check)the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted. Print name: Date: Sign here: X Phone Number: Address: Social Security Number: __— __-__-- ❑ I do not have a Social Security Number Part 6.Children's racial and ethnic identities(optional) Mark one or more racial identities: Mark one ethnic identity: ❑Asian ❑American Indian or Alaska Native ❑ Hispanic or Latino ❑White ❑Native Hawaiian or Other Pacific Islander ❑Not Hispanic or Latino ❑Black or African American ❑ Other - Don't fill out this part._This is for school use:only. Annual Income Conversion:Weekly x:52,Every 2 Weeks x 26 Twice A Month x 24 Monthly x 12 Total Income:; -' Per: ❑.Week, ❑Every 2 Weeks,❑Twice A Month,LJ Month,Cl Year. Household size: Categorical Eligibility:_;Date Withdrawn: Eligibility:Free_ Reduced Dented_Reason: Temporary:Free_ Reduced_ Time Period: ` (expires after_days) - Determining Official's Signature Date: .Confirming Official's Signature: Date: Follow-up Official's Signature: Date: 65