Free and Reduced Price Meals Application 24/25SY

2024-25 Evergreen Community Charter School Free and Reduced Price School Meals Household Application

Before you begin…

there are a few things you should know.

If you received a letter from the school saying that your children were automatically approved (directly certified) for free meals for the 2024–2025 school year because someone in your household participates in Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), or Food Distribution Program on Indian Reservations (FDPIR) then you do not need to submit an application. Please notify the school if there are children in your household who are not listed on the letter.

We need only one application for all the children in your household that attend Evergreen.

Eligibility for free or reduced price school meal benefits is based on any one of these three things:
- your total household income and size in the month the application is filled out, or the month before, or
- your child’s individual status as foster, homeless, migrant or runaway, or
- participation in an assistance program by any member of your household
Your US citizenship or immigration status does not affect your eligibility for free and reduced price benefits.
Things you'll need...

If you have this information handy, it will make the application process fast and easy.
- If you participate in FNS(formerly SNAP), D-SNAP, TANF, or FDPIR you will need to know your case number (not your card or account number).
- If you do not participate in any of the above assistance programs, you will need to report your total household income. In that case…
  - if anyone in your household has a job, you may need to reference the earnings statements or pay stubs to report your gross income, which is different from the amount you actually receive in your paycheck.
  - if anyone receives Social Security or retirement benefits, you may need to gather the benefit statements to report the amount and frequency of the payments.
  - you may also need to reference other financial documents for additional sources of income.
Still not sure if you have everything you need? Don’t worry! The income section of the application contains detailed instructions and explanations about the sources of income you must include, and you can gather additional information then.
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.

Enter the name of the adult household member completing the application.
Name*

First NameLast Name
Date*

YearMonthDay
Date
Signature*

Clear
*Deliberate misrepresentation of information may subject applicants to prosecution under applicable State and Federal law.

Students

List the names of the students in your household that attend Evergreen
Student's Name*

First NameLast Name
Student's Name

First NameLast Name
Student's Name

First NameLast Name
Student's Name

First NameLast Name
Student's Name

First NameLast Name

Please list any additional Infants or Children who live in your household
Child's Name

First NameLast Name
Child's Name

First NameLast Name
Child's Name

First NameLast Name
Child's Name

First NameLast Name

If anyone in your household participates in FNS (formerly SNAP), TANF, or FDPIR then you students are eligible for free school meals.

A household is defined as a group of people, related or unrelated, that usually live together and share income and expenses.

This includes grandparents or other extended family members that are living with you. It also includes people that are not currently living with you, but are only away on a temporary basis, like kids that are away at college. It includes people regardless of age or whether they earn or receive income.

If you need more detailed information, please contact Evergreen.
If anyone in your household (including you) currently participates in any of the following programs, please select one or more of the checkboxes below.

Food and Nutrition Services (FNS)Temporary Assistance for Needy Families (TANF)Food Distribution on Indian Reservations (FDPIR)Disaster SNAP (D-SNAP)

Please enter your case number for the program (or ONE of the programs) in which you participate. Please indicate the program AND case number in the box below*

Do any of the students you have listed live with you under a formal (court-ordered) foster care arrangement?

YesNo
Do any of the students you have listed receive assistance under the McKinney-Vento Homeless Assistance Act? If not, but your household lacks a permanent address, or stays together in a shelter, hotel, or other temporary housing arrangement, contact Evergreen for help.

YesNo
Do any of the students you have listed participate in the Migrant Education Program (MEP)? If not, but you moved your household into a different school district within the last three years to gain or look for temporary/seasonal work in agriculture or fishing, contact Evergreen for help.

YesNo
Do any of the students you have listed participate in a program under the Runaway and Homeless Youth Act? If not, but he/she chose to leave his/her prior family or household, contact Evergreen for help.

YesNo
If you answered yes to any of the above questions, please indicate which children:
Names of children

The next two questions ask about your children's income. If they have no sources of income of thier own you may skip the questions by clicking the Next button.
Do any children/students in your household have earnings from work? Enter total GROSS (before taxes and deductions) amount.
Do children/students in your household have income from other sources?

Okay, now let’s talk about the adults in your household.

Remember, for the purposes of applying for school meal benefits, a household is defined as a group of people, related or unrelated, that usually live together and share income and expenses. Don't forget about:
- grandparents or other extended family members that are living with you
- people that are not currently living with you, but are only away on a temporary basis, like:
  - kids that are away at college
  - members of your family that are in the military, and are deployed
Include people regardless of age or whether they earn or receive income.

Not including yourself, what other adults live in the household?
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name

For each ADULT household member (including yourself) please enter all types and amounts of GROSS income received. If no income is listed for an adult in your household it certifies there is no income to report for that adult*

Thanks, you are almost done!

Please provide the last four digits of the Social Security number for the person that signed at the beginning of the application. If that person does not have a Social Security number, please type 'No SSN.'

Note: United States citizenship or immigration status is not a condition of eligibility for free and reduced price benefits. The non-cash benefits received through the school meal programs are not subject to public charge consideration. In other words, you will not be deported, denied entry to the country, or denied permanent status because you apply for or receive school meal benefits.
Last 4 digits of your Social Security Number (or type "no SSN" if you do not have one)*
Last 4 digits of SSN
Total Number of Household Members (Children and Adults)*

Contact Info

Please enter your contact information so that we can reach you in case there are any issues with your application. This information is optional, but we strongly encourage you to provide it. An email address is required.
Phone Number
Please enter a valid phone number.
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

This is an optional question for information we collect about students that attend Evergreen.

We are required to ask for information about the race and ethnicity of the students that are applying for the program.

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.
Child(ren)'s Ethnicity:

Hispanic or LaninxNot Hispanic or Latinx
Child (ren)'s Racial Identity

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhite

Legal Statements

Almost done! Please read and acknowledge the following legal statements.

Use of Information Statement
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 submit all needed information, 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 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 or other FDPIR identifier for your child 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 your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs.

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 look into violations of program rules.

USDA Non-Discrimination Statement
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: http://www.ascr.usda.gov/complaint_ﬁling_cust.html, 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. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.

This institution is an equal opportunity provider.
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Students

Contact Info