Dear Parent/Guardian:

 

Your child may be eligible to receive healthy school meals at a reduced price or free.  Following are questions and answers about who is eligible and how to apply.

 

 

Meal Charges

Elementary

Middle or Jr. High

High School

Full

Price

Reduced

Price

Full

Price

Reduced

Price

Full

Price

Reduced

Price

Lunch

1.85

.40

2.25

.40

2.25

.40

Breakfast

1.10

.30

1.20

.30

1.20

.30

After School Snack

     

     

     

     

     

     

 

1.     Do I need to fill out an application for each child?  No. Complete one application for all students in your household.  We cannot approve an application that is not complete, so be sure to fill out all required information.  Return the completed application to: Darren Shupe, Elementary Principal or Doug Beisel, JR/SR High Principal.

2.     Who can get free meals?  Students in households getting Food Stamps, TAF or FDPIR and most foster children can get free meals regardless of your income.  Also, students in your household can get free meals if your household income is within the free limits on the Federal Income Guidelines.

3.     Can a homeless, runaway or migrant student get free meals?  If you have not already been informed that the student will get free meals, to see if he or she qualifies, please call Jon Pfau, Superintendent at 785-863-2539 .

4.            Who can get reduced price meals?  Students in your household can get reduced price meals if your household income is within the reduced price limits on the Federal Income Chart (see the back of the application form).

5.            If I already received a letter from the school or Kansas State Department of Education that says my child(ren) will receive free meals, do I need to complete an application?  No, you do not need to complete an application.   If you did not receive a letter from the school notifying you that your child(ren) will get free meals, bring the Kansas State Department of Education letter to the school.

6.            I get WIC. Can my child(ren) get free meals?  Students in households participating in WIC may be eligible for reduced price or free meals.  Please fill out an application.

7.     Will the information I give be checked?  Yes, we may ask you to send written proof.

8.     If I donÕt qualify now, may I apply later?  Yes.  You may apply at any time during the school year if your household size goes up, income goes down, or if you start getting Food Stamps, TAF, FDPIR or other benefits.  If you lose your job, your children may be able to get reduced price or free meals during the unemployment period.

9.     What if I disagree with the schoolÕs decision about my application?  You should talk to school officials. You also may ask for a hearing by calling or writing:  Jon Pfau, 404 Park Street, Oskaloosa, KS 66066, 785-863-2539.

10.   May I apply if someone in my household is not a U.S. citizen?  Yes. You or your child(ren) do not have to be a U.S. citizen to qualify for reduced price or free meals.

11.   Who should I include as members of my household?  Include all people living in your household, related or not (such as grandparents, other relatives, or friends).  Include yourself and all children who live with you.

12.   What if my gross income is not always the same?  List the amount that you normally get.  For example, if your normal gross income is $1,000 each month, but you missed some work last month and only got $900, put down that you get $1,000 per month.  If you normally get overtime, include it, but not if you get it only sometimes.

13.   We are in the military, do we include our housing allowance as income?  If your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income.  All other allowances must be included in your gross income.

 

If you have other questions or need help, call 785-863-2539.

Si necesita ayuda, por favor llame al telŽfono 785-863-2539.

Si vous voudriez dÕaide, contactez nous au numero 785-863-2539.

 

Sincerely,

 

 

 

 

How to Apply for Reduced Price or Free School Meals

 

If your household gets FOOD STAMPS, TAF or FDPIR, follow these instructions:

Part 1: 

á       Enter each studentÕs first and last name.

á       Enter each studentÕs school and grade. 

á       Enter a Food Stamp, TAF or FDPIR case number for each student.

Part 2:  Sign and date the form.  A Social Security number is not necessary.

Part 3:  Complete this part if you choose to.

 

If you are applying for a FOSTER CHILD, follow these instructions:

Part 1:  Use a separate application for each foster child. 

á       Check the box on line 1. 

á       Enter the studentÕs first and last name.

á       Enter the studentÕs school and grade. 

á       Check the box if the student has zero personal use income. 

á       If the student has personal use income, enter the amount and circle the Frequency code that shows how often the income is received.

Part 2:  Sign and date the form. A Social Security number is not necessary.

Part 3:  Complete this part if you choose to.

 

ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:

Part 1: Report the names and GROSS income for all household members from last month.  Gross income is the amount earned BEFORE taxes and any other deductions.  This is NOT the same as take-home pay.  The gross amount should be listed on the pay stub. 

á       Students: 

á       Enter the studentÕs first and last name

á       Enter the studentÕs school and grade. 

á       Check the box if the student has zero income. 

á       If the student has income, record the amount in the column that best describes the source of the income (i.e. Earnings from Work or Other Regular Income) and circle the Frequency code that shows how often the income is received.

á       All Other Household Members:  

á       List the first and last name of each person living in your household, related or not (such as grandparents, other relatives, or friends). Include yourself and all children living with you who are not already listed as students. Attach another sheet of paper if more space is needed.

á       Check the box if the person has zero income.

á       List the gross income the person earned from work and circle the Frequency code that shows how often the income is received.

á       List the amount the person got last month from other income including welfare, child support, alimony, retirement pensions, Social Security, WorkerÕs Compensation, unemployment, strike benefits, Supplemental Security Income (SSI), veteranÕs benefits (VA benefits), disability benefits, regular contributions from people who do not live in your household, and ANY OTHER INCOME.  Circle the Frequency code that shows how often the income is received.

á       If the household has income from self-employment (such as from a self-owned business, farm or rental income), report net income in the Earnings from Work columns.  See the back side of the application form for instructions on reporting self-employment income. 

á       If the household is in the Military Housing Privatization Initiative do NOT include this housing allowance.

á       Check the box if this person is not working due to strike, lay-off, injury or short-term disability.

Part 2:  An adult household member must sign the form and list his or her Social Security number or write ÒNONEÓ if he or she does not have one.

Part 3:  Complete this part if you choose to.

2008-2009 Application for Child Nutrition Program Benefits

Important!  Carefully follow instructions.  An incomplete application cannot be approved.  Complete one application per foster child OR household.  Return completed application to school.

1. HOUSEHOLD MEMBERS

GROSS INCOME BEFORE ANY DEDUCTIONS

 

 

Check if

Foster

Child

 

List Names

of ALL

Household Members

 

Complete these columns ONLY

for students enrolled in

<Enter Sponsor's Name.>

 

 

Check if ZERO Income

 

Frequency:  Circle ONE next to each income amount:  W=Weekly,         E2=Every 2 Weeks, 2M=Twice a Month, M=Monthly, Y=Yearly

Check if NOT working due to strike,

lay-off, injury or short-term disability.

Earnings from Work

Other Regular Income

First Name

Last Name

School Name

Grade

Food Stamp,

TAF or FDPIR Case Number

Amount

Circle

Frequency

Amount

Circle

Frequency

1. 

 

 

 

 

 

$                 

W   E2    2M   M   Y

$                 

W   E2    2M   M   Y

2.   

 

 

 

 

 

$                 

W   E2    2M   M   Y

$                 

W   E2    2M   M   Y

3.   

 

 

 

 

 

$                 

W   E2    2M   M   Y

$                 

W   E2    2M   M   Y

4.   

 

 

 

 

 

$                 

W   E2    2M   M   Y

$                 

W   E2    2M   M   Y

5.   

 

 

 

 

 

$                 

W   E2    2M   M   Y

$                 

W   E2    2M   M   Y

6.   

 

 

 

 

 

$                 

W   E2    2M   M   Y

$                 

W   E2    2M   M   Y

7.   

 

 

 

 

 

$                 

W   E2    2M   M   Y

$                 

W   E2    2M   M   Y

8.   

 

 

 

 

 

$                 

W   E2    2M   M   Y

$                 

W   E2    2M   M   Y

9.   

 

 

 

 

 

$                 

W   E2    2M   M   Y

$                 

W   E2    2M   M   Y

10.             

 

 

 

 

 

$                 

W   E2    2M   M   Y

$                 

W   E2    2M   M   Y

2. ADULT HOUSEHOLD MEMBER INFORMATION – Refer to the Privacy Act Statement on the reverse side of this application.

Print Name______________________________________________________   Daytime Phone _________________________________   Evening Phone _________________________________

Address, City, State, Zip___________________________________________________________________________________________   Email _________________________________________

I certify (promise) that all information on this application is true and that all income is reported.  I understand that the school will receive Federal and State funds based on the information I give;
school officials may verify the information; and if I purposely give false information, my child(ren) may lose meal benefits and I may be prosecuted under applicable Federal and State criminal statutes.

Sign Here X _________________________________________   Social Security Number (SSN) ________________________ OR write NONE if you have no SSN     Date ___________________

3. Ethnic Identity (optional) – Check one:                 Hispanic or Latino   NOT Hispanic or Latino

    Racial Identity (optional) – Check one or more:    Asian     White     Black or African American     American Indian or Alaska Native     Native Hawaiian or Pacific Islander     Other

FOR SCHOOL USE ONLY.  DO NOT WRITE BELOW.

Application Type (check one) 

 Total Household Income:  $____________________    Household Size: ___________

     HouseholdÕs Income Frequency – Circle ONE:    W     E2      2M       M       Y      Multiple=Yearly

 Food Stamps/TAF/FDPIR

 Foster Child – Annual personal use income:  $______________

Application Status

ApprovedÉÉÉÉÉÉ..  Free  OR    Reduced Price

Temporarily ApprovedÉ  Free  OR    Reduced Price   Expires On: ____________________ 

DeniedÉÉÉÉÉÉÉ..  Income over allowed amount   Incomplete/missing:

Notes:________________________________________________________________________

Determining OfficialÕs Signature:                                                                                                                      Approval/Denial Date:                                                    Notification Date:

ProcessorÕs Initials:                                   Confirming OfficialÕs Signature (ONLY for applications to be verified):                                                                                 Review Date:

 
Your children may qualify for reduced price or free meals if your household income falls within the limits on this chart.

 

2008-2009 Federal Income Eligibility Guidelines

 

Household size

 

Yearly

 

Monthly

Twice a Month

Every 2 Weeks

 

Weekly

1

19,240

1,604

802

740

370

2

25,900

2,159

1,080

997

499

3

32,560

2,714

1,357

1,253

627

4

39,220

3,269

1,635

1,509

755

5

45,880

3,824

1,912

1,765

883

6

52,540

4,379

2,190

2,021

1,011

7

59,200

4,934

2,467

2,277

1,139

8

65,860

5,489

2,745

2,534

1,267

Each additional person:

6,660

555

278

257

129

 

 

 

 

 

 

 

 

 

 

 

 

 

Income from Self Employment:  Self-employed persons may use income tax records for the preceding calendar year as a base to project the current yearÕs net income, unless the current monthly income provides a more accurate measure.  Report income derived from the business venture less operating costs incurred in the generation of that income.  Deductions for personal expenses such as interest on home payments, medical expenses, and other similar non-business deductions are not allowed in reducing gross business income.  Additional income from other kinds of employment must be treated as separate and apart from the income generated or lost from your business venture.  For example, if you operated a business at a net loss, but held additional employment for which a salary was received, the income for purposes of applying for reduced price or free meals would be the income from the salary only.  The loss from the business cannot be deducted from a positive income earned in other employment.  For purposes of this application, it is not possible to report a negative income from any business venture.  The least income possible is zero (no income).  The necessary information for arriving at allowable income from private business operation may be taken from your most recent U.S. Individual Income Tax Return - Form 1040.  Add together the amounts reported on the following lines:

                                                        LINE 12   $_______________  Business Income or (Loss)

                                                        LINE 13   $_______________  Capital Gain or (Loss)

                                                        LINE 14   $_______________  Other Gains or (Losses)

                                                        LINE 17   $_______________  Rental real estate, royalties, partnerships, S corporations, trusts, etc.

                                                        LINE 18   $_______________  Farm Income or (Loss)

                                                        TOTAL     $_______________  Report yearly income in Part 1, Gross Income Before Any Deductions.

 

Privacy Act Statement: This explains how we will use the information you give us.  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, we cannot approve your child for reduced price or free meals.  You must include 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 Food Stamp Program, Temporary Assistance for Families (TAF) 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 reduced price or free 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.

 

Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington DC 20250-9410 or call (800) 795-3272 or
(202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.