reduced lunch application

FreeandReducedPriceSchoolMealsApplicationLettertoHouseholdsPage1of2July2011‐Language

FREE AND REDUCED PR ICE SCHOOL MEALS APPL ICAT ION AND VER IF ICAT ION FORMS

DearParent/Guardian:

WhileCathedralHighSchooldoesnotparticipateintheFederalSchoolLunchProgramwebelievechildrenneedhealthymealstolearn.ThereforeCathedralHighSchooloffershealthymealseveryschooldayandwillprovideafreeorreducedpricedlunchat.40centsforchildrenwhoqualifyforfreemealsorforreducedpricemeals.Studentswhoareeligibleforthisbenefitwillreceiveamealvaluedat3.60.Parentmustcompletetheformandmeetthefederalguidelinesforfreeandreducedlunchinordertoquality.Pleasereadtheinstructionprovided.SubmityourformstoDr.Greerandyouwillbenotifiedofyoureligibility.

1. DOINEEDTOFILLOUTANAPPLICATIONFOREACHCHILD?No.Completetheapplicationtoapplyforfreeorreducedpricemeals.UseoneFreeandReducedPriceSchoolMealsApplicationforallstudentsinyourhousehold.Wecannotapproveanapplicationthatisnotcomplete,sobesuretofilloutallrequiredinformation.Returnthecompletedapplicationto:Dr.TomGreer5225E.56thSt.Indianapolis,IN46226.

2. WHOCANGETFREEMEALS?AllchildreninhouseholdsreceivingFoodStampsorTANFcangetfreemealsregardlessofyourincome.Also,yourchildrencangetfreemealsifyourhousehold’sgrossincomeiswithinthefreelimitsontheFederalIncomeEligibilityGuidelines.

3. CANFOSTERCHILDRENGETFREEMEALS?Yes,fosterchildrenthatareunderthelegalresponsibilityofafostercareagencyorcourt,areeligibleforfreemeals.Anyfosterchildinthehouseholdiseligibleforfreemealsregardlessofincome.

4. CANHOMELESS,RUNAWAY,ANDMIGRANTCHILDRENGETFREEMEALS?Yes,childrenwhomeetthedefinitionofhomeless,runaway,ormigrantqualifyforfreemeals.Ifyouhaven’tbeentoldyourchildrenwillgetfreemeals,pleasecallore‐mailDr.TomGreerat(317)543‐4944ortgreer@gocathedral.comtoseeiftheyqualify.

5. WHOCANGETREDUCEDPRICEMEALS?YourchildrencangetlowcostmealsifyourhouseholdincomeiswithinthereducedpricelimitsontheFederalEligibilityIncomeChart,shownonthisapplication.

6. SHOULDIFILLOUTANAPPLICATIONIFIRECEIVEDALETTERTHISSCHOOLYEARSAYINGMYCHILDRENAREAPPROVEDFORFREEMEALS?Pleasereadtheletteryougotcarefullyandfollowtheinstructions.Calltheschoolat(317)543‐4944ifyouhavequestions.

7. MYCHILD’SAPPLICATIONWASAPPROVEDLASTYEAR.DOINEEDTOFILLOUTANOTHERONE?Yes.Yourchild’sapplicationisonlygoodforthatschoolyearandforthefirstfewdaysofthisschoolyear.Youmustsendinanewapplicationunlesstheschooltoldyouthatyourchildiseligibleforthenewschoolyear.

8. IGETWIC.CANMYCHILD(REN)GETFREEMEALS?ChildreninhouseholdsparticipatinginWICmaybeeligibleforfreeorreducedpricemeals.Pleasefilloutanapplication.

9. WILLTHEINFORMATIONIGIVEBECHECKED?Yesandwemayalsoaskyoutosendwrittenproof.

FreeandReducedPriceSchoolMealsApplicationLettertoHouseholdsPage2of2July2011‐Language

10. IFIDON’TQUALIFYNOW,MAYIAPPLYLATER?Yes,youmayapplyatanytimeduringtheschoolyear.Forexample,childrenwithaparentorguardianwhobecomesunemployedmaybecomeeligibleforfreeandreducedpricemealsifthehouseholdincomedropsbelowtheincomelimit.

11. WHATIFIDISAGREEWITHTHESCHOOL’SDECISIONABOUTMYAPPLICATION?Youshouldtalktoschoolofficials.Youalsomayaskforahearingbycallingorwritingto:DuaneEmery5225E.56thSt.Indianapolis,IN46226orbycalling(317)968‐7360.

12. MAYIAPPLYIFSOMEONEINMYHOUSEHOLDISNOTAU.S.CITIZEN?Yes.Youoryourchild(ren)donothavetobeU.S.citizenstoqualifyforfreeorreducedpricemeals.

13. WHOSHOULDIINCLUDEASMEMBERSOFMYHOUSEHOLD?Youmustincludeallpeoplelivinginyourhousehold,relatedornot(suchasgrandparents,otherrelatives,orfriends)whoshareincomeandexpenses.Youmustincludeyourselfandallchildrenlivingwithyou.Ifyoulivewithotherpeoplewhoareeconomicallyindependent(forexample,peoplewhoyoudonotsupport,whodonotshareincomewithyouoryourchildren,andwhopayapro‐ratedshareofexpenses),donotincludethem.

14. WHATIFMYINCOMEISNOTALWAYSTHESAME?Listtheamountthatyounormallyreceive.Forexample,ifyounormallymake$1000eachmonth,butyoumissedsomeworklastmonthandonlymade$900,putdownthatyoumade$1000permonth.Ifyounormallygetovertime,includeit,butdonotincludeitifyouonlyworkovertimesometimes.Ifyouhavelostajoborhadyourhoursorwagesreduced,useyourcurrentincome.

15. WEAREINTHEMILITARY.DOWEINCLUDEOURHOUSINGALLOWANCEASINCOME?Ifyougetanoff‐basehousingallowance,itmustbeincludedasincome.However,ifyourhousingispartoftheMilitaryHousingPrivatizationInitiative,donotincludeyourhousingallowanceasincome.

16. MYSPOUSEISDEPLOYEDTOACOMBATZONE.ISHERCOMBATPAYCOUNTEDASINCOME?No,ifthecombatpayisreceivedinadditiontoherbasicpaybecauseofherdeploymentanditwasn’treceivedbeforeshewasdeployed,combatpayisnotcountedasincome.Contactyourschoolformoreinformation.

17. MYFAMILYNEEDSMOREHELP.ARETHEREOTHERPROGRAMSWEMIGHTAPPLYFOR?TofindouthowtoapplyforFoodStampsorotherassistancebenefits,contactyourlocalassistance.

Wecannotapproveanapplicationthatisnotcomplete,sobesuretosilloutalltherequiredinformation.Returnthecompletedapplicationsto:

Dr.TomGreerCathedralHighSchool5225E.56thSt.Indianapolis,IN46226

Ifyouhaveotherquestionsorneedhelp,call(317)543‐4944.

Sinecesitaayuda,porfavorllamealteléfono:(317)543‐4944.

FreeandReducedPriceSchoolMealsApplicationInstructionsforApplyingPage1of2July2011‐Language

INSTRUCTIONSFORAPPLYING

AHOUSEHOLDMEMBERISANYCHILDORADULTLIVINGWITHYOU.

IFYOURHOUSEHOLDRECEIVESBENEFITSFROMFOODSTAMPSORINDIANATANF,FOLLOWTHESEINSTRUCTIONS:

Part 1: List all household members and the name of school for each child.  

Part 2: List the case number for any household member (including adults) receiving Food Stamps or Indiana TANF benefits. 

Part 3: Skip this part. 

Part 4: Skip this part. 

Part 5: Sign the form. The last four digits of a Social Security Number are not necessary. 

Part 6: Answer this question if you choose to.IFNOONEINYOURHOUSEHOLDGETSFOODSTAMPSORINDIANATANFBENEFITSANDIFANYCHILDINYOURHOUSEHOLDISHOMELESS,AMIGRANTORRUNAWAY,FOLLOWTHESEINSTRUCTIONS:   

Part 1: List all household members and the name of school for each child. 

Part 2: Skip this part. 

Part 3: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box. 

Part 4: Complete only if a child in your household isn’t eligible under Part 3. See instructions for All Other Households. 

Part 5: Sign the form. The last four digits of a Social Security Number are not necessary if you didn’t need to fill in Part 4.  

Part 6: Answer this question if you choose to.

IFYOUAREAPPLYINGFORAFOSTERCHILD,FOLLOWTHESEINSTRUCTIONS:If all children in the household are foster children:   

Part 1: List all foster children and the school name for each child.  Check the box indicating the child is a foster child.   

Part 2: Skip this part. 

Part 3: Skip this part. 

Part 4: Skip this part. 

Part 5: Sign the form. The last four digits of a Social Security Number are not necessary. 

Part 6: Answer this question if you choose to.  

If some of the children in the household are foster children:   

Part 1: List all household members and the name of school for each child. For any person, including children, with no income, 

you must check the “No Income” box.  Check the box if the child is a foster child.   

Part 2: If the household does not have a case number, skip this part.   

Part 3: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box .If not, skip this part. Part 4: Follow these instructions to report total household income from this month or last month.  

Box 1–Name: List all household members with income.  

Box 2 –Gross Income and How Often It Was Received: For each household member, list each type of income 

received for the month. You must tell us how often the money is received—weekly, every other week, twice a month 

or monthly.  For earnings, be sure to list the gross income, not the take‐home pay. Gross income is the amount 

earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. For 

other income, list the amount each person got for the month from welfare, child support, alimony, pensions, 

retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), and disability 

benefits. Under All Other Income, list Worker’s Compensation, unemployment or strike benefits, regular contributions 

from people who do not live in your household, and any other income. Do not include income from SNAP, FDPIR, 

WIC, Federal education benefits and foster payments received by the family from the placing agency.  For ONLY the 

self‐employed, under Earnings from Work, report income after expenses. This is for your business, farm, or rental 

FreeandReducedPriceSchoolMealsApplicationInstructionsforApplyingPage2of2July2011‐Language

property.  If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as 

income. 

Part 5: Adult household member must sign the form and list the last four digits of their Social Security Number (or mark the box 

if s/he doesn’t have one). 

Part 6: Answer this question, if you choose.  

ALLOTHERHOUSEHOLDS,INCLUDINGWICHOUSEHOLDS,FOLLOWTHESEINSTRUCTIONS:Part 1: List all household members and the name of school for each child. For any person, including children, with no income, 

you must check the “No Income” box.    

Part 2: If the household does not have a case number, skip this part.   

Part 3: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box .If not, skip this part. Part 4: Follow these instructions to report total household income from this month or last month.  

Box 1–Name: List all household members with income.  

Box 2 –Gross Income and How Often It Was Received: For each household member, list each type of income 

received for the month. You must tell us how often the money is received—weekly, every other week, twice a month 

or monthly.  For earnings, be sure to list the gross income, not the take‐home pay. Gross income is the amount 

earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. For 

other income, list the amount each person got for the month from welfare, child support, alimony, pensions, 

retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), and disability 

benefits. Under All Other Income, list Worker’s Compensation, unemployment or strike benefits, regular contributions 

from people who do not live in your household, and any other income. Do not include income from SNAP, FDPIR, 

WIC, Federal education benefits and foster payments received by the family from the placing agency.  For ONLY the 

self‐employed, under Earnings from Work, report income after expenses. This is for your business, farm, or rental 

property. Do not include income from SNAP, FDPIR, WIC or Federal education benefits.  If you are in the Military 

Privatized Housing Initiative or get combat pay, do not include these allowances as income. 

Part 5: Adult household member must sign the form and list the last four digits of their Social Security Number (or mark the box 

if s/he doesn’t have one). 

Part 6: Answer, this question if you choose. 

FreeandReducedPriceSchoolMealsApplicationApplicationPage1of3July2011‐Language

FREEANDREDUCEDPRICESCHOOLMEALSFAMILYAPPLICATION

PART1.ALLHOUSEHOLDMEMBERS

Names of all household members 

(First, Middle Initial, Last) 

Name of school for each 

child/or indicate  “NA” if 

child is not in school 

Check if a foster child (legal responsibility of welfare 

agency or court)   

* If all children listed below are foster children, skip 

to Part 5 to sign this form.   

Check if NO income

Part2.BENEFITS

IFANYMEMBEROFYOURHOUSEHOLDRECEIVESFOODSTAMPS,ORINDIANATANF,PROVIDETHENAMEANDCASENUMBERFORTHEPERSONWHORECEIVESBENEFITSANDSKIPTOPART5.IFNOONERECEIVESTHESEBENEFITS,SKIPTOPART3.

NAME:____________________________________________________________________CASENUMBER:__________________________________________________________

PART3.IFANYCHILDYOUAREAPPLYINGFORISHOMELESS,MIGRANT,ORARUNAWAYCHECKTHEAPPROPRIATEBOX.HOMELESSMIGRANTRUNAWAY

PART4.TOTALHOUSEHOLDGROSSINCOME.You must tell us how much and how often.

1. NAME 

(List only household members with 

income)  

2. GROSS INCOME AND HOW OFTEN IT WAS RECEIVED 

Earnings From Work 

before deductions 

Welfare, child support, 

alimony 

Pensions, retirement,  

Social Security, SSI,  

VA benefits 

All Other Income 

(Example)  Jane Smith $199.99/weekly $149.99/every other week $99.99/monthly $50.00/monthly

$______/___________________ $______/___________________ $______/___________________ $______/___________________

$______/___________________ $______/___________________ $______/___________________ $______/___________________

$______/___________________ $______/___________________ $______/___________________ $______/___________________

$______/___________________ $______/___________________ $______/___________________ $______/___________________

$______/___________________ $______/___________________ $______/___________________ $______/___________________

$______/___________________ $______/___________________ $______/___________________ $______/___________________

FreeandReducedPriceSchoolMealsApplicationApplicationPage2of3July2011‐Language

PART5.SIGNATUREANDLASTFOURDIGITSOFSOCIALSECURITYNUMBER(ADULTMUSTSIGN)

An adult household member must sign the application. If Part 4 is completed, the adult signing the form also must list the last four digits of his or 

her Social Security Number or mark the “I do not have a Social Security Number” box. (See Statement on the back of this page.) 

Icertify(promise)thatallinformationonthisapplicationistrueandthatallincomeisreported.IunderstandthattheschoolwillgetFederalfundsbasedontheinformationIgive.Iunderstandthatschoolofficialsmayverify(check)theinformation.IunderstandthatifIpurposelygivefalseinformation,mychildrenmaylosemealbenefits,andImaybeprosecuted.

Signhere:___________________________________________________________________ Printname:_________________________________________________________________

Date:_________________________________________________________________________

Address:_____________________________________________________________________ PhoneNumber:_____________________________________________________________

City:__________________________________________________________________________ State:____________________________ ZipCode:_______________________________

LastfourdigitsofSocialSecurityNumber:***‐**‐____________IdonothaveaSocialSecurityNumber

PART6.CHILDREN’SETHNICANDRACIALIDENTITIES(OPTIONAL)

Chooseoneethnicity: Chooseoneormore(regardlessofethnicity):

Hispanic/Latino

NotHispanic/Latino

Asian AmericanIndianorAlaskaNativeBlackorAfricanAmerican

WhiteNativeHawaiianorotherPacificIslander

DO NOTFILLOUTTHISPART.THISISFORSCHOOL USEONLY.

AnnualIncomeConversion:Weeklyx52,Every2Weeksx26,TwiceAMonthx24Monthlyx12

TotalIncome:____________Per:Week,Every2Weeks,TwiceAMonth,Month,YearHouseholdsize:________

CategoricalEligibility:___DateWithdrawn:________Eligibility:Free___Reduced___Denied___

Reason:________________________________________________________________________________

Temporary:Free_____Reduced_____TimePeriod:___________(expiresafter_____days)

DeterminingOfficial’sSignature:________________________________________________Date:______________

ConfirmingOfficial’sSignature:_____________________________Date:___________

VerifyingOfficial’sSignature:_______________________________Date:________

FreeandReducedPriceSchoolMealsApplicationApplicationPage3of3July2011‐Language

Yourchildrenmayqualifyforfreeorreducedpricemealsifyourhouseholdincomefallsatorbelowthelimitsonthischart.SEETHECHARTSONTHEFOLLOWINGPAGESTOSEEIFYOUMAYQUALIFYFORFREEORREDUCEDPRICEMEALS.

TheRichardB.RussellNationalSchoolLunchActrequirestheinformationonthisapplication.Youdonothavetogivetheinformation,butifyoudonot,wecannotapproveyourchildforfreeorreducedpricemeals.Youmustincludethelastfourdigitsofthesocialsecuritynumberoftheadulthouseholdmemberwhosignstheapplication.ThelastfourdigitsofthesocialsecuritynumberisnotrequiredwhenyouapplyonbehalfofafosterchildoryoulistaSupplementalNutritionAssistanceProgram(SNAP),TemporaryAssistanceforNeedyFamilies(TANF)ProgramorFoodDistributionProgramonIndianReservations(FDPIR)casenumberorotherFDPIRidentifierforyourchildorwhenyouindicatethattheadulthouseholdmembersigningtheapplicationdoesnothaveasocialsecuritynumber.Wewilluseyourinformationtodetermineifyourchildiseligibleforfreeorreducedpricemeals,andforadministrationandenforcementofthelunchandbreakfastprograms.WeMAYshareyoureligibilityinformationwitheducation,health,andnutritionprogramstohelpthemevaluate,fund,ordeterminebenefitsfortheirprograms,auditorsforprogramreviews,andlawenforcementofficialstohelpthemlookintoviolationsofprogramrules.

Non‐discriminationStatement:Thisexplainswhattodoifyoubelieveyouhavebeentreatedunfairly.“InaccordancewithFederalLawandU.S.DepartmentofAgriculturepolicy,thisinstitutionisprohibitedfromdiscriminatingonthebasisofrace,color,nationalorigin,sex,age,ordisability.Tofileacomplaintofdiscrimination,writeUSDA,Director,OfficeofAdjudication,1400IndependenceAvenue,SW,Washington,D.C.20250‐9410orcalltollfree(866)632‐9992(Voice).IndividualswhoarehearingimpairedorhavespeechdisabilitiesmaycontactUSDAthroughtheFederalRelayServiceat(800)877‐8339;or(800)845‐6136(Spanish).USDAisanequalopportunityproviderandemployer.”

17006 Federal Register / Vol. 77, No. 57 / Friday, March 23, 2012 / Notices

Authority: 42 U.S.C. 1758(b)(1).

Dated: March 19, 2012. Jeffrey J. Tribiano, Acting Administrator. [FR Doc. 2012–7036 Filed 3–22–12; 8:45 am]

BILLING CODE 3410–30–P

DEPARTMENT OF AGRICULTURE

Food and Nutrition Service

Special Supplemental Nutrition Program for Women, Infants and Children (WIC): Income Eligibility Guidelines

AGENCY: Food and Nutrition Service (FNS), USDA. ACTION: Notice.

SUMMARY: The Department announces adjusted income eligibility guidelines to be used by State agencies in determining the income eligibility of persons applying to participate in the Special Supplemental Nutrition Program for Women, Infants and Children Program (WIC). These income eligibility guidelines are to be used in conjunction with the WIC Regulations. DATES: Effective Date: July 1, 2012.

FOR FURTHER INFORMATION CONTACT: Donna Hines, Branch Chief, Policy Branch, Supplemental Food Programs Division, FNS, USDA, 3101 Park Center Drive, Alexandria, Virginia 22302, (703) 305–2746. SUPPLEMENTARY INFORMATION:

Executive Order 12866 This notice is exempt from review by

the Office of Management and Budget under Executive Order 12866.

Regulatory Flexibility Act This action is not a rule as defined by

the Regulatory Flexibility Act (5 U.S.C. 601–612) and thus is exempt from the provisions of this Act.

Paperwork Reduction Act of 1995 This notice does not contain reporting

or recordkeeping requirements subject to approval by the Office of Management and Budget in accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3507).

Executive Order 12372 This program is listed in the Catalog

of Federal Domestic Assistance Programs under No. 10.557, and is subject to the provisions of Executive

Order 12372, which requires intergovernmental consultation with State and local officials (7 CFR part 3015, subpart V, 48 FR 29114, June 24, 1983, and 49 FR 22676, May 31, 1984).

Description

Section 17(d)(2)(A) of the Child Nutrition Act of 1966, as amended (42 U.S.C. 1786(d)(2)(A)), requires the Secretary of Agriculture to establish income criteria to be used with nutritional risk criteria in determining a person’s eligibility for participation in the WIC Program. The law provides that persons will be income eligible for the WIC Program only if they are members of families that satisfy the income standard prescribed for reduced-price school meals under section 9(b) of the Richard B. Russell National School Lunch Act (42 U.S.C. 1758(b)). Under section 9(b), the income limit for reduced-price school meals is 185 percent of the Federal poverty guidelines, as adjusted. Section 9(b) also requires that these guidelines be revised annually to reflect changes in the Consumer Price Index. The annual revision for 2012/2013 was published by the Department of Health and Human

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