List ALL household members who are infants, children, and students up to and including grade 12 (if more space are required for additional names, attach another sheet of paper)

Contact information and adult signature

I certify that all information on this application is true and that all income is reported. I understand that the information is given in connection with the receipt of Federal funds, and that school officials may verify 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.

Sources of Income for Children

Sources of Child Income	Example(s)
- Earning from work	- A child has a job where they earn a salary or wages
- Social Security -Disability Payments -Survivor's Benefits	- A child is blind or disabled and receives Social Security benefits -A parent is disabled, retired, or deceased, and their child receives Social Security benefits
- Income from person outside of the household	- A friend or extended family member regularly gives a child spending money
- Income from any other source	- A child receives income from a private pension fund, annuity, or trust

Sources of Income for Adults

Earnings from Work	Public Assistance/ Alimony/ Child Support	Pensions/ Retirement/ All Other Income
- Salary, wages, cash bonuses - Net income from self- employment (farm or business) -Strike benefits If you are in the U.S. Military: - Basic pay and cash bonuses (do NOT include combat pay, FSSA or privatized housing allowances) -Allowances for off-base housing, food, and clothing	- Unemployment benefits - Worker's compensation - Supplemental Security Income (SSI) -Cash assistance from State or local government - Alimony payments Child support payments - Veteran's benefits	- Social Security (including railroad retirement and black lung benefits) - Private Pensions or disability - Income from trusts or estates Annuities - Invested income Earned interest Rental income - Regular cash payments from outside the household

We are required to ask 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.

The Richard B Russell Nation 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. You may use a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance to Needy Families (TANF) Program, or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifiers for your child or when you indicate that all children in your household are homeless, migrant, or runaway. 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 Summer Food Service Program. 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 investigate violations of program rules. In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter 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. 20250-5430; (2) fax (202) 690-7442; or (3) email program.intake@usda.gov This institution is an equal opportunity provider.

Annual Income Conversion: Weekly x 52, Bi-Weekly x 26, Twice a Month x 24, Monthly x 12