MILLENNIUM COMMUNITY SCHOOL HOUSEHOLD INFORMATION SURVEY (SCHOOL MEAL FORM)

MILLENNIUM COMMUNITY SCHOOL HOUSEHOLD INFORMATION SURVEY (SCHOOL MEAL FORM)
Millennium Community School will participate in the Community Eligibility Provision (CEP) under the National School Lunch Program (NSLP Under this option, all children in the school receive a breakfast/lunch at no charge regardless if they complete this form. However, to determine eligibility for various additional state and federal program benefits that your child’s school may qualify for, please complete, sign and return this application to your school building if your income falls within or below the guidelines listed in the following chart.

Guidelines to be effective from July 1, 2024 through June 30, 2025
If any member of your household receives Supplemental Nutrition Assistance Program (SNAP) (formerly food stamps) or Ohio Works First (OWF) benefits, provide the name and 7-digit case number for the person who receives the benefits then proceed to Section 4. If no one receives these benefits, start with Section 1.
Name
7-digit Case Number

Section 1 -Size of Family
Indicate the total number of individuals living in household, including all adults and children:*

Section 2 - Student Information

Complete for each student Pre-K through grade 12*

	Last Name	First Name	Birth Date (MM-DD-YY)	School
1
2
3
4
5
6
7
8

Section 3 - TOTAL MONTHLY HOUSEHOLD INCOME

Report income for all members of household excluding foster children. If you have reported a case number above, please do not complete this section. Proceed to section 4.

	Income Amount	Check if No Income
Gross Monthly Earnings: Wages, Salary, Commissions
Monthly Welfare Payments, Child Support, Alimony
Monthly Payments from Pensions, Retirement, Social Security
Monthly Dividends or Interest on Savings
Monthly Worker’s Compensation, Unemployment, Strike Benefit
Other Monthly Income (SSI, VA, Disability, Farm, other)

Section 4 - Signature
If income section is completed, the adult signing the form must also list the last four (4) digits of his other Social Security number or check the “I do not have a Social Security number” box below.

I certify (promise) that all information on this application is true and that all income is reported. I understand the school will be eligible for certain federal and/or state funds based on the information I give. I understand that the school officials may verify (check) the information. I understand that if I purposely give false information, my child may lose benefits and I may be prosecuted.
Sign Here: X Date*

Clear
Sign Here: X Date*

MonthDayYear
Date
Print Name*
Last Four (4) Digits of Social Security Number: XXX-XX
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Email
example@example.com
Should be Empty:

MILLENNIUM COMMUNITY SCHOOL HOUSEHOLD INFORMATION SURVEY (SCHOOL MEAL FORM)

Section 1 -Size of Family

Section 2 - Student Information

Section 3 - TOTAL MONTHLY HOUSEHOLD INCOME

Section 4 - Signature