Free and Reduced-Price Household Application for 2025-2026 – West Virginia Dept. of Education Effective from July 1, 2025 to June 30, 2026
1. Names of ALL Children in School, Center, or Camp
Child's Name
Last Name
First Name
Date of Birth
/
Month
/
Day
Year
Date
Mark if Child is in Foster Care
Grade
Name of School, Center or Camp
Do you need to add another child?
Yes
No
Child's Name
Last Name
First Name
Date of Birth
/
Month
/
Day
Year
Date
Mark if Child is in Foster Care
Grade
Name of School, Center or Camp
Do you need to add another child?
Yes
No
Child's Name
Last Name
First Name
Date of Birth
/
Month
/
Day
Year
Date
Mark if Child is in Foster Care
Grade
Name of School, Center or Camp
Do you need to add another child?
Yes
No
Child's Name
Last Name
First Name
Date of Birth
/
Month
/
Day
Year
Date
Mark if Child is in Foster Care
Grade
Name of School, Center or Camp
Do you need to add another child?
Yes
No
Child's Name
Last Name
First Name
Date of Birth
/
Month
/
Day
Year
Date
Mark if Child is in Foster Care
Grade
Name of School, Center or Camp
2. SNAP/TANF
If any member of your household receives SNAP or TANF, indicate which program and provide the 10-digit case # (If any, SKIP TO PART 5)
SNAP
TANF
10-digit Case Number
3.HOMELESS, MIGRANT, RUNAWAY
If the child you are applying for is homeless migrant or runaway check the appropriate box and call your county contact.
Homeless
Migrant
Runaway
4. HOUSEHOLD MEMBERS AND GROSS INCOME FROM LAST MONTH
List each person in the household. For each person who receives income, write the amount received and fill in how often it is received. Monthly Payments Name (Last, First)Monthly EarningsPublic Assistance, from from Work Child Support, List everyone in the Household. (Before Deductions) Alimony Attach a separate sheet if needed.
Name
Last
First
Check if No Income
Monthly Earnings from Work
Public Assistance, Child Support, Alimony
Monthly Payments from Pensions, Retirement, Social Security
Other Monthly Income
Do you need to add another household member?
Yes
No
Name
Last
First
Check if No Income
Monthly Earnings from Work
Public Assistance, Child Support, Alimony
Monthly Payments from Pensions, Retirement, Social Security
Other Monthly Income
Do you need to add another household member?
Yes
No
Name
Last
First
Check if No Income
Monthly Earnings from Work
Public Assistance, Child Support, Alimony
Monthly Payments from Pensions, Retirement, Social Security
Other Monthly Income
Do you need to add another household member?
Yes
No
Name
Last
First
Check if No Income
Monthly Earnings from Work
Public Assistance, Child Support, Alimony
Monthly Payments from Pensions, Retirement, Social Security
Other Monthly Income
Do you need to add another household member?
Yes
No
Name
Last
First
Check if No Income
Monthly Earnings from Work
Public Assistance, Child Support, Alimony
Monthly Payments from Pensions, Retirement, Social Security
Other Monthly Income
Totals
Total Number of Persons in Household
Total Monthly Income Before Deductions
5. Signature and Social Security Number (Adult must sign)
An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list the last 4 digits of 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 system may get federal funds based on the information I give. / understand that school officials may verify (check) the information. I understand that if I purposely give false information, my child(ren) may lose meal benefits, and I may be prosecuted
Signature
Todays Date
/
Month
/
Day
Year
Date
Last 4 Digits of Social Security Number
I do not have a Social Security Number
Printed Name
Address
Mailing Address
Street Address Line 2
City
State
ZIP Code
Home Phone Number
Work Phone Number
6. Children's Race and Ethnicity - (You do not have to complete this part to receive free and reduced-price meals)
Mark one or more racial identities from this group:
Asian
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
White
And mark one ethnic identity from this group:
Hispanic or Latino
Not Hispanic or Latino
7. Other Benefits - (You do not have to complete this part to receive free and reduced price meals.)
Yes, school officials may use the information provided on this application to determine my child(ren)’s eligibility for free textbooks,workbooks, and other school supplies.
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