WAPS Application for Educational Benefits

Application for Educational Benefits

Free and Reduced Lunch Form
All families in Winona Area Public Schools are asked to fill out the Application for Educational Benefits (Free and Reduced Lunch Form).

Families who have access to a laptop or desktop computer are encouraged to fill out their application through the Infinite Campus Parent Portal.

If you do not have access to a laptop or desktop computer, you can use your mobile phone or tablet to complete this application.

Complete one application per household for all children.
STEP 1

List ALL Household Members who are infants, children, and students up to and including grade 12: >>>>>>> scroll to the right for all fields *

	Child’s First Name	Child’s Last Name	Middle Initial	School	Grade	Birthdate	Foster Child?
1
2
3
4
5

Definition of Household Member: “Anyone who is living with you and shares income and expenses, even if not related.” Children in Foster care and children who meet the definition of Homeless, Migrant or Runaway are eligible for free meals. Read How to Apply for Free and Reduced Price School Meals for more information
STEP 2
Do Any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, MFIP or FDPIR? Medical assistance does not qualify. If NO > Go to STEP 3. If YES >Enter SNAP, MFIP or FDPIR Case Number (between 4-9 digits, do not report EBT card number)
If yes, please enter the case number here:
fill in only 1 case number here.
STEP 3

Report income for all household members
Last Four Digits of Social Security Number (SSN) of ADULT Household Member
Or Check box if Adult has no Social Security Number (SSN)

No SSN
Total Household Members (Children and Adults) *
Adult Income

For each Household Member listed, if they do receive income, report total gross income only. If they do not receive income from any source, write ‘0’ or leave any fields blank. You are certifying (promising) that there is no income to report. Not sure what income to include here? Scroll down and review “Sources of Income” at the bottom of this form for information.

Gross Earnings from Working at Jobs *

	Names of all household members not listed in STEP 1 (including yourself) even if they do not receive income.	Report income before deductions or taxes in whole dollars	Frequency
1
2
3
4

Are you self-employed or a farmer? (if no, skip to next question)

	Names of all household members not listed in STEP 1 (including yourself) even if they do not receive income.	How often are work earnings received?	Net income from farm or self-employment. Do not duplicate elsewhere.
1
2
3
4

Any other gross income? (If no, skip to next question)

	Names of all household members not listed in STEP 1 (including yourself) even if they do not receive income.	How often are work earnings received?	SSI, Unemployment, Public Assistance, Child Support and Others in the "Sources of Income for Adults" below
1
2
3
4

Child Income

Sometimes children in the household earn or receive income, such as from a part time job or SSI. Please include the TOTAL income received by all children listed in STEP 1. Do not include income received by adults. Not sure what to include here? Scroll down and review “Sources of Income” at the bottom of this form for information.
Child income amount
How Often?

Weekly Bi-Weekly 2x Month Monthly
STEP 4
Contact Info and Signature

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 benefits, and I may be prosecuted under applicable State and Federal laws.
Opt-out

I have checked this box if I do not want my information shared with Minnesota Health Care Programs or WAPS Programs as allowed by state law. Leave this box blank to allow for school district fees to be waived for athletics, activities or field trips.
Name of adult signing this form *
Email (optional)
example@example.com
Phone Number (optional)

Area Code Phone Number
Street Address and Apt # (if available) *
City *
Zip *
Signature of adult *

Clear
Today’s date *

Month Day Year
Date
OPTIONAL
Children's Racial and Ethnic Identities
We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children’s eligibility for free or reduced price meals.
Ethnicity (check one):

Hispanic or Latino Not Hispanic or Latino
Race (check one or more):

Asian American Indian or Alaskan Native Black or African American Native Hawaiian or Other Pacific Islander White
Sources of Income For Adults

Earnings from Work
- Salary, wages, cash bonuses (before deductions or taxes)
- Net income from self-employment (farm or business)
- If you are in the U.S. Military:
  - Basic pay and cash bonuses (do NOT included combat pay, FSSA or privatized housing allowences)
  - Allowances for off-base housing, food and clothing
Public Assistance/Alimony/Child Support
- Cash assistance from state or local government
- Supplemental security income
- Unemployement benefits
- Worker's compensation
- Alimony payments
- Child support payments
- Veterans benefits
- Strike benefits
All Other Income
- Social security
- Disability benefits
- Regular income from trusts or estates
- Annuities
- Investment income
- Rental income
- Regular cash payments from outside household
Sources of Income For Children

Sources of Child Income
- Earnings from work
- Social security
  - Disability Payments
  - Survivor Benefits
- Income from person outside the household
- Income from any other source
Examples
- A child has a regular full or part-time job where they earn a salary or wages
- A child is blind or disabled and receives Social Security
- A parent is disabled, retired, or deceased, and their child receives Social Security benefits
- A friend or extended family member regularly gives a child spending money
- A child receives regular income from a private pension fund, annuity or trust
The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.

At public school districts, each student’s school meal status also is recorded on a statewide computer system used to report student data to MDE as required by state law. MDE uses this information to: (1) Administer state and federal programs, (2) Calculate compensatory revenue for public schools, and (3) Judge the quality of the state’s educational program.

Nondiscrimination statement: In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA.

The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the
nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400
Independence Avenue, SW, Washington, D.C. 20250-9410; or (2) fax: (833) 256-1665 or (202) 690-7442; or (3) email: program.intake@usda.gov
This institution is an equal opportunity provider.
Should be Empty:

Application for Educational Benefits

STEP 1

STEP 2

STEP 3

STEP 4

Contact Info and Signature

OPTIONAL

Children's Racial and Ethnic Identities