2024-25 Free and Reduced Meals Application

2023-2024 Application for Free and Reduced Price School Meals or Free Milk

Complete one application perhousehold.

STEP 1: List ALL Household Members who are infants, children, and students up to and including grade 12

Definition of Household Member. "Anyone who is living with you & 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

Child 1 Name*

First NameLast Name

Child 1 Age*

Write name of Child 1's school, or "not in school"*

If Child 1 is a student, write their grade

Child 1 is a

Foster ChildHomeless, Migrant, or Runaway

Child 2 Name

First NameLast Name

Child 2 Age

Write name of Child 2's school, or "not in school"

If Child 2 is a student, write their grade

Child 2 is a

Foster ChildHomeless, Migrant, or Runaway

Child 3 Name

First NameLast Name

Child 3 Age

Write name of Child 3's school, or "not in school"

If Child 3 is a student, write their grade

Child 3 is a

Foster ChildHomeless, Migrant, or Runaway

Child 4 Name

First NameLast Name

Child 4 Age

Write name of Child 4's school, or "not in school"

If Child 4 is a student, write their grade

Child 4 is a

Foster ChildHomeless, Migrant, or Runaway

Child 5 Name

First NameLast Name

Child 5 Age

Write name of Child 5's school, or "not in school"

If Child 5 is a student, write their grade

Child 5 is a

Foster ChildHomeless, Migrant, or Runaway

Child 6 Name

First NameLast Name

Child 6 Age

Write name of Child 6's school, or "not in school"

If Child 6 is a student, write their grade

Child 6 is a

Foster ChildHomeless, Migrant, or Runaway

STEP 2: Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANT, or FDPIR (NOT Medicaid)

If you answered NO > Complete STEPS 3 and 4

If you answered YES > Write your 9 digit SNAP, TANF, or FDPIR case number here than SKIP to STEP 4

Case Number

Write only 1 case number in this space

STEP 3: Report Income for ALL Household Members (Skip this step if you answered "Yes" to STEP 2)

A: Child Income

Sometimes children in the household earn or receive income. Please include the TOTAL Income received by all children listed in STEP 1 here.

Child income 1

How often do you receive child income 1?

WeeklyBi-weekly2x a monthMonthly

Child income 2

How often do you receive child income 2?

WeeklyBi-weekly2x a monthMonthly

B. All Adult Household Members (including yourself)

List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income For each HouseholdMemberlisted, if they do receive income, report total gross Income (before taxes) for each source in whole dollars only.

If they do not receive income from any source, write '0'. If you enter '0' or leave any fields blank, you are certifying (promising) that there is no income to report.

Name of Adult Household Member 1*

First NameLast Name

Adult 1 Earnings from work*

How often does Adult 1 receive earnings from work?*

WeeklyBi-Weekly2x a MonthMonthly

Adult 1 Earnings from public assistance/child support/alimony

How often does Adult 1 receive earnings from public assistance/child support/alimony?

WeeklyBi-Weekly2x a MonthMonthly

Adult 1 Earnings from pension, retirement, social security, SSI, VA benefits, or any other earnings

How often does Adult 1 receive earnings from pension, retirement, social security, SSI, VA benefits, or any other earnings?

Name of Adult Household Member 2

First NameLast Name

Adult 2 Earnings from work

How often does Adult 2 receive earnings from work?

WeeklyBi-Weekly2x a MonthMonthly

Adult 2 Earnings from public assistance/child support/alimony

How often does Adult 2 receive earnings from public assistance/child support/alimony?

WeeklyBi-Weekly2x a MonthMonthly

Adult 2 Earnings from pension, retirement, social security, SSI, VA benefits, or any other earnings

How often does Adult 2 receive earnings from pension, retirement, social security, SSI, VA benefits, or any other earnings?

Name of Adult Household Member 3

First NameLast Name

Adult 3 Earnings from work

How often does Adult 3 receive earnings from work?

WeeklyBi-Weekly2x a MonthMonthly

Adult 3 Earnings from public assistance/child support/alimony

How often does Adult 3 receive earnings from public assistance/child support/alimony?

WeeklyBi-Weekly2x a MonthMonthly

Adult 3 Earnings from pension, retirement, social security, SSI, VA benefits, or any other earnings

How often does Adult 3 receive earnings from pension, retirement, social security, SSI, VA benefits, or any other earnings?

Name of Adult Household Member 4

First NameLast Name

Adult 4 Earnings from work

How often does Adult 4 receive earnings from work?

WeeklyBi-Weekly2x a MonthMonthly

Adult 4 Earnings from public assistance/child support/alimony

How often does Adult 4 receive earnings from public assistance/child support/alimony?

WeeklyBi-Weekly2x a MonthMonthly

Adult 4 Earnings from pension, retirement, social security, SSI, VA benefits, or any other earnings

How often does Adult 4 receive earnings from pension, retirement, social security, SSI, VA benefits, or any other earnings?

Total Household Members Children and Adults*

Last Four Digits of Social Security Number SSN of Primary Wage Earner or Other Adult Household Member

Check here if no SSN

No SSN

STEP 4 : Contact information and adult 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 law"

Street Address if available

Apt

City*

State*

Zip*

Daytime Phone (optional)

Name of adult completing the form*

Signature of adult completing the form*

Todays date*

Date