USDA Free/Reduced form 2005-06

PART 2a IF YOU DON'T HAVE basic food, TANF, or FDPIR, LIST CHILDREN HERE

Child's Name

FIRST

Date of Birth

MULTI-USE SCHOOL YEAR 2005–06 Exhibit IA

APPLICATION FOR FREE AND REDUCED-PRICE MEALS

To apply for free and reduced-price meals for your children, complete this application, sign your name and return the application to school. If your household receives benefits from Basic Food, TANF, or FDPIR, complete only Parts 1, 4, and 5. If your household does not receive benefits from Basic Food, TANF, or FDPIR, complete Parts 2a, 2b, 4, and 5. If you are applying for free and reduced-price meals for a foster child, complete parts 3, 4, and 5. For assistance please call your child's school and ask for help with the free and reduced-price meals application. Foster children need their own application.

PART 1 LIST CHILDREN ONLY OF BASIC FOOD, TANF, or FDPIR HOUSEHOLDS
Child's Name FIRST	MI	LAST	Basic Food or TANF (X)	FDPIR (X)	Case Number	School	Room	Grade

PART 2b LIST HOUSEHOLD MEMBERS AND INCOME

Do not complete this section if you completed Part 1. List the names of EVERYONE living in your household, including yourself and any children listed in Part 2a. Write the amount of income (MONEY BEFORE DEDUCTIONS) each person now gets PER MONTH on the same line as his/her name and where it comes from, such as earnings, welfare, pensions, or other. If income is received other than monthly, use the income conversion chart provided below. Do not include foster children.

NAMES of Household Members			Gross MONTHLY Earnings (before deductions)		MONTHLY Welfare Payment, Child Support, Alimony	MONTHLY Payments from Pensions, Retirement, Social Security	Any Other MONTHLY Income
FIRST	MI	LAST	Job 1	Job 2
1.
2.
3.
4.
5.
6.
7.

MONTHLY INCOME CONVERSION: Weekly x 4.33; Every Two Weeks x 2.15; Twice a Month x 2

PART 3: LIST FOSTER CHILD: Write "0" if the child has no personal income
Child's Name	Child's Monthly Personal Use Income	School	Room	Grade

PART 4: RACIAL/ETHNIC: You are not required to answer this question

WHITE BLACK, or AFRICAN AMERICAN HISPANIC or LATINO

AMERICAN INDIAN OR ALASKA NATIVE ASIAN NATIVE HAWAIIAN or OTHER PACIFIC ISLANDER

PART 5: SIGNATURE, SOCIAL SECURITY NUMBER, AND ADDRESS

An adult household member must sign the application before it can be approved. If you do not have a social security number, check the "I do not have a social security number" box. If you listed a Basic Food, TANF, or FDPIR number for your child, or are applying for a foster child, a social security number is not needed.

I certify that all of the above information is true and correct and that all income is reported. I understand that this information is being given for the receipt of federal funds; that school officials may verify the information on the application; and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws.

Please sign here: X

Signature of Adult Household Member Date

PRINTED NAME OF ADULT HOUSEHOLD MEMBER

MAILING ADDRESS

HOME TELEPHONE NUMBER

SOCIAL SECURITY NUMBER

I do not have a social security number

CITY AND ZIP CODE

WORK TELEPHONE NUMBER

PLEASE TURN OVER

FORM SPI NSLP M-280 EX IA (Rev. 5/05) Page 8 Bulletin No. 039-05 OSPI/Child Nutrition Services

May 2005

Exhibit IA

PART 6: OTHER BENEFITS: Your family may be eligible for MORE benefits. You do not have to complete this part to receive free and reduced-price meals. CHECK AND SIGN BELOW.

Do you need free health insurance for your children? Please check this box and sign below if you are interested in applying for health coverage including doctor visits, prescriptions, hospital, dental care, eyeglasses and more! Please do not check the box if you already receive Medicaid and get a monthly DSHS green and white card (coupon). For more information call 1-877-KIDSNOW (543-7669).

Check here and sign below if you want to give school officials permission to use the information provided on this application to determine your children's eligibility for reduced traffic safety education fees (if available) and other state or federally funded school related benefits.

I understand that I will be releasing information that shows that I am applying for free and reduced-price benefits under Child Nutrition Programs. For these purposes only, I waive my confidentiality.

Please sign here: X

Signature of Parent/Guardian Date

*Privacy Act Statement: National School Lunch Act (Section 9) - requires that, unless your child's Basic Food, TANF, or FDPIR case number is provided, you must include the social security number of the adult household member signing the application or indicate that the household member signing the application does not have a social security number. Provision of a social security number is not mandatory, but if a social security number is not given or an indication is not made that the signer does not have such a number, the application cannot be approved. The social security number may be used to identify the household member in carrying out efforts to verify the correctness of information stated on the application. These verification efforts may be carried out through program reviews, audits, and investigations and may include contacting employers to determine income, benefits, contacting the State employment security office to determine the amount of benefits received and checking the documentation produced by household members to prove the amount of income received. These efforts may result in a loss or reduction of benefits, administrative claims or legal actions if incorrect information is reported.

SCHOOL USE ONLY - DO NOT WRITE BELOW THIS LINE

LEA APPROVAL/DENIAL

Basic Food/TANF/FDPIR Household Total Household Monthly Income $

Income Household

Foster Child Total Household Size

APPLICATION APPROVED FOR: TEMPORARY APPROVAL FOR: APPLICATION DENIED BECAUSE:

Free Meals Free Meals Income Over Allowed Amount

Reduced-Price Meals Incomplete/Missing Information

Date Temporary Other:

Approval Expires:

Date Notice Sent Signature of Approving Official Date

VERIFICATION: Verification procedures must not delay approval of application

Date Selected for Verification

Not Confirmed

Confirmed

Basic Food/TANF Office

Notice of Eligibility

Response Due From Household

Second Notice Sent

MONTHLY INCOME		COMMENTS	RESULTS		REASON FOR ELIGIBILITY CHANGE
$				No Change		Income
	Wage Stubs			Free to Reduced		Household Size
	Written Documents			Ineligible		Refuse to Cooperate
	Collateral Contact			Reduced-Price to Free		Other:
	Agency Records			Free to Paid
	Other			Reduced-Price to Paid
Date of Change Date Adverse Notice Sent Signature of Verifying Official Date

FORM SPI NSLP M-280 EX IA (Rev. 5/05) Page 9 Bulletin No. 039-05 OSPI/Child Nutrition Services

May 2005