• Part 1.

    Enrolled Children: list names of all enrolled children

    NOTE: if you are enrolling more than three children, please complete the paper copy version of this form.

  • (Child #1) Date of Birth   Pick a Date   

  • (Child #2) Date of Birth   Pick a Date   

  • (Child #3) Date of Birth   Pick a Date 

  • Part 2.

    Benefits: If any member of your household received SNAP or TANF assistance, provide the type of benefit and case number for the person who receives benefits. If no one receives these benefits, skip to part 3.

  • Part 3.

    Total Household Gross Income - You must tell us how much and how often.

    List only household members not listed in Part 1.

    NOTE: if you have more than three household members not listed in Part 1, please complete the paper copy version of this form.

  • (Household Member #1)
    Name:
    Earnings before deductions:
    Frequency of pay:               
    Welfare, child support, alimony:   
    Frequency of pay:      
    Pensions, retirement, Social Security, SSI, VA benifits:     
    Frequency of pay:       
    Other income:      
    Frequency of pay:      
    Mark "X" if no income:      

  • (Household Member #2)
    Name:
    Earnings before deductions:
    Frequency of pay:               
    Welfare, child support, alimony:   
    Frequency of pay:      
    Pensions, retirement, Social Security, SSI, VA benifits:     
    Frequency of pay:       
    Other income:      
    Frequency of pay:      
    Mark "X" if no income:      

  • (Household Member #3)
    Name:
    Earnings before deductions:
    Frequency of pay:               
    Welfare, child support, alimony:   
    Frequency of pay:      
    Pensions, retirement, Social Security, SSI, VA benifits:     
    Frequency of pay:       
    Other income:      
    Frequency of pay:      
    Mark "X" if no income:      

  • Part 4.

    Signature and Last Four Digits of Social Security Number (Adult must sign) - An adult household member must sign this form. If Part 3 is completed, the adult signing the form must also list the last four digits of his or her Social Security Number or mark the "I do not have a Social Security Number" box. (See Privacy Act Statement below)

    I certify that all information on this form is true and that all income is reported. I understand that the center will get Federal funds based on the information I give; that center officials may verify the information on the form; and that deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws.

  • Clear
  •  / /

  • Mark "X" if you do not have a Social Security Number:

  • City: 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 the participant 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 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 for the participant or other (FDPIR) identifier 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 the participant is eligible for free or reduced price meals, and for administration and enforcement of the Program. Part 5. Participant's ethnic and racial identities (optional) Mark one ethnic identity:Mark one or more racial identities: Hispanic or LatinoAsian Not Hispanic or LatinoWhite Native Hawaiian or Other Pacific Islander Black or African American Don't fill out this part. This is for official use only. Annual Income Conversion: Weekly X 52, Every 2 Weeks x 26, Twice A Month X 24, Monthly X 12

  • Should be Empty: