School Year Submission of the Free and Reduced-Price Meal Policy and Direct Certification Information

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1 June 19, 2012 M E M O R A N D U M TO: FROM: SUBJECT: System Superintendents Nancy Rice, Director School Nutrition Program School Year Submission of the Free and Reduced-Price Meal Policy and Direct Certification Information A school food authority (SFA) is required annually to confirm or update its Policy statement to the department. Effective with the 2001 school year, this is accomplished through our School Approval Module (SAM) on the Internet. The superintendent, through the designation of School Nutrition users, is responsible for the SFA Certification in SAM. Your currently approved School Year 2012 Policy contains updates and changes you have made to the original policy. Please update the appropriate items as directed in SAM. To maintain the integrity of the Policy and to update it for , please incorporate all attachments, and file the UPDATE WORKSHEET with your approved Policy as amended in an active file. All documents being submitted for approval are to be sent to your area consultant. When Policy updates are needed during the school year, contact your area consultant who will provide access to SAM for making these changes; she will subsequently approve the changes. To print a new copy of the entire Free and Reduced-Price Meal Policy prototype, you will find it on the Internet at If you need a translation of the application, the instructions, and/or the letter, you will find them on the Internet at The English version of the application and all other available languages are updated for For SY , each school system will continue to be responsible for the notification of households of students directly certified for free meals. Prototype notification and procedures are found in the Policy available on the Internet at Please contact your area consultant or Ms. Theresa Latta at (404) or at if you have questions. NR:tl:mj Enclosure cc: School Nutrition Directors U:\Adm\Correspo\Policy\2012\SY12 FRP Policy-Direct Certification Letter.doc Making Education Work for All Georgians 1662 Towers East Atlanta, GA (404) Fax: (404)

2 School Nutrition Program 1662 Twin Towers East Atlanta, Georgia POLICY STATEMENT FREE AND REDUCED-PRICE MEALS SCHOOL YEAR KEEP THIS BOOKLET ON FILE In accordance with State and Federal law, the prohibits discrimination on the basis of race, color, religion, national origin, sex, disability, or age in its educational and employment activities. Inquiries regarding the application of these practices may be addressed to the General Counsel of the, 2052 Twin Towers East, Atlanta, Georgia, 30334, (404) 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 USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C or call toll free (866) (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer.

3 INTRODUCTION All schools participating in the federally assisted National School Lunch Program and School Breakfast Program must make these benefits available to eligible children each year. The (GaDOE) annually issues this free and reduced-price policy statement to all school food authorities (SFAs) to assist in the correct implementation of these program requirements. Each participating SFA must adopt and implement the free and reduced-price policy statement. The policy statement or addendum and attachments, along with any modifications must be approved by the GaDOE by October 15 of each year for the SFA to continue to receive State and Federal reimbursement. The free and reduced-price policy statement consists of: 1. a Certification of Acceptance form; 2. the Policy Statement; 3. the income eligibility guidelines as issued by USDA each year; 4. application and verification procedures; 5. prototype parent letters and applications with instructions; 6. direct certification attachments; 7. confidentiality memorandum; 8. public release; 9. meal accountability and collection procedures; 10. verification attachments 11. civil rights compliance requirements 12. assurances for Special Assistance Certification and Reimbursement Alternatives Provisions II and III; and for the Meal Supplement for Afterschool Care Program 13. on-site review forms 14. edit check forms 15. Seamless Summer Option 16. Spanish translation of the Free and Reduced Price Meals Application POLICY TERMS The School Food Authority (SFA) assures the (GaDOE) that the school system will uniformly implement the following policy to determine children's eligibility for free and reduced-price meals in all child nutrition programs under its jurisdiction. In fulfilling its responsibilities, the SFA: A. agrees to serve meals free to children from families whose income is at or below that listed in the Eligibility Scale (Attachment A). B. agrees to serve meals at the reduced-price of not more than 40 cents for lunch and 30 cents for breakfast to children from families whose income is at or below that listed in the Eligibility Scale (Attachment A). C. agrees to provide these benefits to children from families experiencing unemployment which causes the family income to fall within the criteria specified in the Eligibility Scale (Attachment A). D. agrees that there will be no physical segregation of, or any other discrimination against, any child because of inability to pay the full price of the meal. The names of children eligible to receive free July 2012 Page 2 of 12

4 or reduced-price meals shall not be published, posted or announced in any manner and there shall be no overt identification of any such children by use of special tokens or tickets or by any other means. Further assurance is given that children eligible for free or reduced-price meals shall not be required to: 1. work for their meals, 2. use a separate dining room or separate area of the dining room, 3. go through a separate serving line, 4. enter the dining room through a separate entrance, 5. eat meals at a different time, or 6. eat a different meal from the meal sold to children paying the full price. E. agrees that in the operation of child nutrition programs, no child shall be discriminated against because of race, color, national origin, age, sex, or disability, and F. agrees to establish and use a fair hearing procedure in cases of appeal by parents of the school's decisions on applications and for school officials' challenges to the correctness of information contained in an application or of the continued eligibility of any child for free or reduced-price meals. During the appeal and hearing, the child will continue to receive free or reduced-price meals. A record of all such appeals and challenges and their dispositions shall be retained for five years after the end of the fiscal year to which they pertain. Prior to initiating the hearing procedure, the parent or local school official may request a conference to provide an opportunity for the parent and school official to discuss the situation, present information, and obtain an explanation of data submitted in the application and decisions rendered. Such a conference shall not in any way prejudice or diminish the right to a fair hearing. The hearing procedure shall provide: 1. a publicly announced, simple method for making an oral or written request for a hearing, 2. an opportunity to be assisted or represented by an attorney or other person, 3. an opportunity to examine, prior to and during the hearing, the documents and records presented to support the decision under appeal, 4. that the hearing shall be held with reasonable promptness and convenience and that adequate notice shall be given as to the time and place of the hearing, 5. an opportunity to present oral or documentary evidence and arguments supporting a position without undue interference, 6. an opportunity to question or refute any testimony or other evidence and confront and cross-examine any adverse witness, 7. that the hearing shall be conducted and the decision made by a hearing official who did not participate in the decision under appeal, or any previous conference, July 2012 Page 3 of 12

5 8. that the decision of the hearing official shall be based on the oral and documentary evidence presented at the hearing and made a part of the hearing record, 9. that the parties concerned and any designated representative thereof shall be notified in writing of the decision of the hearing official, 10. that a written record shall be prepared with respect to each hearing. This record shall include the decision under appeal; any documentary evidence and a summary of any oral testimony presented at the hearing; the decision of the hearing official, including the reasons therefore and a copy of the notification to the parties concerned of the hearing official's decisions, and 11. that such written record of each hearing shall be preserved for a period of five years after the end of the fiscal year to which it pertains and shall be available for examination by the parties concerned or their representatives at any reasonable time and place during such period. G. agrees to designate a determining official to review applications and make determinations of eligibility. In accordance with State Rule STATEWIDE SCHOOL NUTRITION PROGRAM, this responsibility must be assigned to School Nutrition personnel. This official will use the criteria outlined in this policy to determine which individual children are eligible for free or reduced-price meals. H. agrees to develop and send to each child's parent or guardian a letter (Attachment B or F) including an application form for free and reduced-price meals at the beginning of each school year and whenever there is a change in eligibility criteria, unless specifically exempted from doing so. Parents will be requested to complete the application and return it to the school. Such applications and documentation of action taken will be maintained for five years after the fiscal year to which they pertain or according to the system's records retention schedule, whichever is longer. If audit findings have not been resolved, the records shall be retained beyond the five-year period as long as required for the resolution of issues raised by the audit. Applications may be filed at any time during the year and any parent enrolling a child in a school for the first time, at any time during the year, shall be supplied with such documents. If a child transfers from one school to another under the jurisdiction of the same school food authority, his/her eligibility for free or reduced-price meals will be transferred to and honored by the receiving school. The original application will be on file in the school the child currently attends, and a copy of the application will be available at schools formerly attended unless the applications are filed centrally. All children from a household will receive the same benefits based on income information or categorically if the household receives SNAP or TANF benefits. Parents or guardians will be notified, within 10 working days, of the acceptance or denial of their applications. Children will be served meals immediately upon their establishment of the eligibility. When an application is rejected, parents or guardians will be provided written notification with information as specified in the Notification of Eligibility Determination Letters.. I. agrees to designate a hearing official to establish and use a fair hearing procedure as described in F above. July 2012 Page 4 of 12

6 (Note: This person must be someone not involved in the original eligibility determination or the verification. It is suggested the hearing official be someone who holds a position superior to that of the determining or verification official.) J. agrees to provide to local grassroots organizations and major employers contemplating or experiencing large layoffs, a public release containing the same information outlined in the parent letter at the beginning of the school year. In addition, agrees to provide such a public release whenever there is a change in eligibility criteria, unless specifically exempted from doing so. The State Agency will provide the public release to all newspapers in the state. K. agrees to participate in the statewide direct certification process, according to procedures developed annually by the GaDOE. L. agrees to implement Meal Accountability Procedures which conform to the criteria for a model meal count system as described in the State Prototype Meal Accountability Procedure. M. agrees to submit to the GaDOE any alteration or amendments to the policy, including eligibility criteria, applications, public announcements, collection procedures, etc., for approval prior to implementation. Such changes will be effective only upon approval. N. agrees to select and verify, by November 15, the eligibility of a sample of the approved free and reduced - price applications on file as of October 1. Verification will be achieved using the designated method. O. agrees to maintain for a period of at least five years a description of verification efforts, including: 1. A summary of the verification efforts including the selection process; 2. The total number of applications on file on October 1; and 3. The percentage or number of applications that are/will be verified by November 15. P. agrees to designate a School Nutrition Program (SNP) staff member for the following functions: 1. Verification official to coordinate all system verification activities. 2. Confirming official to certify verification documentation 3. Follow-up official to conduct any follow up of application verification. Q. agrees to provide results of verification process to by March 1 or other date as announced. R. agrees to assign to SNP Personnel primary responsibilities for the following functions: 1. Collecting cash for meals served to students. 2. Counting meals served for the purpose of filing reimbursement claims. 3. Processing applications for approval and denial of free and reduced-price meals. 4. Maintaining a current student eligibility list. 5. Verifying free and reduced-price meal applications. S. agrees to establish a procedure to collect money from children who pay for their meals and to account for the number of free, reduced-price, and full-price meals served. The procedure(s) will be used so that no other child in the school will consciously be made aware by such procedure of the identity of the children receiving reduced-price meals or free meals. See the Collection and Service Procedures. T. agrees that information on the application will be used to determine the child's eligibility for only those benefits allowed by law or designated by the parent/guardian. July 2012 Page 5 of 12

7 U. agrees to perform edits of all meal counts in accordance with 7 CFR 210.8(a)(2), as instructed on the Number of Lunches Served Daily (DE Form 0118) or alternate form. V. agrees not to deny meals to any enrolled student as a disciplinary measure while the student is in attendance at school. W. agrees to establish a provision that complies with the policy for replacement of lost and/or stolen tickets (FNS instruction Rev. 2, 1988 Handling Lost, Stolen and Misused Meal Tickets). See the Collection and Service Procedures. July 2012 Page 6 of 12

8 School Nutrition Program FREE AND REDUCED PRICE MEALS POLICY WORKSHEET SY Free and Reduced-Price Meals Policy Statement The governing body of this School Food Authority (SFA) accepts this Free and Reduced-Price Meals Policy Statement, including the Family Income Eligibility Criteria and all required attachments, as referred to or indicated below: Item 1: GENERAL INFORMATION A. NAME OF SCHOOL FOOD AUTHORITY: B. NAME OF SCHOOL NUTRITION DIRECTOR/MANAGER: C. Check all that apply: 1. School Breakfast Program* 2. National School Lunch Program** a. Meal Supplement for Afterschool Care Program b. Seamless Summer Option D. Indicate Operation Methods of the School Nutrition Programs checked above: (Check all that apply) Pricing Provision 1, 2, 3 Public Charter Non-Pricing RCCI Private Regular **.40 Maximum Reduced-Price Lunch *.30 Maximum Reduced-Price Breakfast Item 2: COLLECTION AND SERVICE PROCEDURES Collection methods will be the same as used in the School Year. Yes No If no, complete section on next page. July 2012 Page 7 of 12

9 Item 2: Collection and Service Procedures List collection and service procedures used by your school(s). (See Attachment J). If your procedure is not listed in Attachment J (Collection and Service Procedures) provide detailed description of the procedure on Attachment N (Alternate Collection Method) for pre-approval. Use multiple lines for schools with more than one collection procedure; indicate grade levels for each procedure. School Name Menu Planning Option (Breakfast only) Collection and Service Procedures Offer vs. Serve Breakfast Lunch Breakfast Lunch S C P S C P Yes/No Yes/No Menu Planning Option: T-Traditional, N-Nutrient Standard, A-Assisted Nutrient Standard, E-Enhanced Collection Methods: S-School Counting Procedure, C-Code Procedure, P-Payment Methods If additional lines are needed for school listing/procedure continue on the next page. July 2012 Page 8 of 12

10 Item 2: Collection and Service Procedures List collection and service procedures used by your school(s). (See Attachment J). If your procedure is not listed in Attachment J (Collection and Service Procedures) provide detailed description of the procedure on Attachment N (Alternate Collection Method) for pre-approval. Use multiple lines for schools with more than one collection procedure; indicate grade levels for each procedure. School Name Menu Planning Option (Breakfast only) Collection and Service Procedures Offer vs. Serve Breakfast Lunch Breakfast Lunch S C P S C P Yes/No Yes/No Collection Methods: S-School Counting Procedure, C-Code Procedure, P-Payment Methods If needed make additional copies of this page and continue. July 2012 Page 9 of 12

11 Item 2: Collection and Service Procedures List collection and service procedure(s) used by your school(s). (See Attachment J). If your procedure is not listed in Attachment J (Collection and Service Procedures) provide detailed description of the procedure on Attachment N (Alternate Collection Method) for pre-approval. Use multiple lines for schools with more than one collection procedure; indicate grade levels for each procedure. School Name Meal Supplement for Afterschool Care Programs School Counting Procedure Code Procedure Payment Method July 2012 Page 10 of 12

12 Item 3: TITLES OF DESIGNATED OFFICIALS A. DETERMINING OFFICIAL: Address & Telephone B. HEARING OFFICIAL: Address & Telephone C. VERIFICATION OFFICIAL: Address & Telephone D. CONFIRMING OFFICIAL: Address & Telephone E. FOLLOW-UP OFFICIAL: Address & Telephone Item 4: MEAL ACCOUNTABILITY PROCEDURE (Check One) I certify that my system is using at a minimum the STATE PROTOTYPE MEAL ACCOUNTABILITY PROCEDURE (Attachment K) Enclosed is my system MEAL ACCOUNTABILITY PROCEDURE for approval by the State Department of Education Item 5: FREE AND REDUCED PARENT LETTER/APPLICATION (Select the application/parent letter you are using) Family instructions/application (Attachment B) Family parent letter (Attachment B) Special Assistance Certification and Reimbursement Alternatives II/III parent letter (Attachment F) Alternate application Alternate parent letter Item 6: VERIFICATION (Check Method Used) Basic Sample Alternate-Random Alternate-Focused No Verification Performed Item 7: ATTACHMENTS The following attachments are adopted with and considered part of this policy statement: Eligibility Standards for Free and Reduced-Price Meals Free and Reduced-Price School Meals Household Application Notification of Eligibility Determination July 2012 Page 11 of 12

13 Special Assistance Certification and Reimbursement Alternatives II/III Parent Letter Collection and Service Procedures State Prototype Meal Accountability Procedure Public Release (Distributed by State) Spanish Version of Application and Verification Letters THIS AGREEMENT IS HEREBY EXECUTED ON BEHALF OF THE: SCHOOL FOOD AUTHORITY (Original Signature) BY: GEORGIA DEPARTMENT OF EDUCATION (Original Signature) BY: Nancy Rice Title: Superintendent, Local School Food Authority Date: Title: Director, School Nutrition Program Date: July 2012 Page 12 of 12

14 Attachment A HOUSEHOLD SIZE FOR APPROVING OFFICIAL ONLY ELIGIBILITY STANDARDS FOR FREE AND REDUCED-PRICE MEALS SY INCOME GUIDELINES FOR FREE MEALS INCOME GUIDELINES FOR REDUCED-PRICE MEALS WEEKLY EVERY TWO WEEKS TWICE PER MONTH MONTHLY YEARLY WEEKLY EVERY TWO WEEKS TWICE PER MONTH MONTHLY YEARLY ,211 14, ,723 20, ,640 19, ,077 1,167 2,333 27, ,035 2,069 24, ,359 1,472 2,944 35, ,153 1,249 2,498 29, ,641 1,777 3,554 42, ,351 1,464 2,927 35, ,922 2,083 4,165 49, ,549 1,678 3,356 40,261 1,102 2,204 2,388 4,775 57, ,747 1,893 3,785 45,409 1,243 2,486 2,693 5,386 64, ,945 2,107 4,214 50,557 1,384 2,768 2,998 5,996 71,947 FOR EACH ADDITONAL FAMILY , ,326 MEMBER ADD CONVERTING INCOME TO ANNUAL: Weekly x 52 Every 2 weeks x 26 Twice a month x 24 Monthly x 12 SNAP or TANF HOUSEHOLDS ALL OTHER HOUSEHOLDS 1. Child(ren) names 1. Child(ren) names 2. SNAP or TANF case number of any household member 2. Names of ALL household members 3. Signature of adult household member 3. Last 4 digits of Social Security Number (SSN) of adult who signs application. 4. The amount of income received by each household member, identified by source. 5. The frequency of how often the income was received. 6. No income box must be checked if no income is received from any source. 7. Signature of an adult household member May 2012

15 Attachment B FREE AND REDUCED PRICE SCHOOL MEALS APPLICATION AND VERIFICATION FORMS Instructions for School Districts School Year This packet contains prototype forms: Required information that must be provided to households: Letter to Households Free and Reduced Price School Meals Application Notice to Households of Approval/Denial of Benefits 1 (notification is required if household is denied) Required information for households selected for verification of eligibility information materials: Notification of Selection for Verification of Eligibility Letter of Verification Results Optional application-related materials that may be provided to households: Sharing Information with Medicaid/SCHIP Sharing Information with Other Programs Notice to Households of Approval/Denial of Benefits 1 (notification is optional if household is approved) Notice of Direct Certification The pages are designed to be printed on 8½ by 11 paper. Some pages may be printed front and back. You will need to identify the benefits that are offered in your school, such as afterschool snacks. The [bold, bracketed fields] indicate where you need to insert school district specific information. For example, you must include your district s no-charge telephone number for verification assistance on the verification materials. If these materials have not been modified to include your State s name for the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance to Needy Families (TANF), State Children s Health Insurance Program (PeachCare), or, if applicable, to add Food Distribution Program on Indian Reservations (FDPIR), you should insert this information as appropriate. This prototype application package includes information regarding the exclusion of housing allowance for those in the Military Housing Privatization Initiative. If this is not pertinent to your school district, please modify as appropriate. Your State agency may require you to submit your application package for approval. If you have questions, contact: School Nutrition Program 1662 Twin Towers East Atlanta, Georgia All households must be notified of their eligibility status. Households with children who are denied benefits must be given written notification of the denial. The notification must advise the household of the reason for the denial of benefits, the right to appeal, instruction on how to appeal, and a statement that the family may re-apply for free and reduced price meal benefits at any time during the school year. Households with children who are approved for free or reduced price benefits may be notified in writing or orally. July 2012

16 Attachment B [Insert School District Letterhead] Date: Dear Parent/Guardian: Children need healthy meals to learn. [Name of School] offers healthy meals every school day. Breakfast costs [$]; lunch costs [$]. Your children may qualify for free meals or for reduced price meals. Reduced price is [$] for breakfast and [$] for lunch. 1. DO I NEED TO FILL OUT AN APPLICATION FOR EACH CHILD? No. Complete the application to apply for free or reduced price meals. Use one Free and Reduced Price School Meals 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: [name, address, phone number]. 2. WHO CAN GET FREE MEALS? All children in households receiving benefits from SNAP or TANF can get free meals regardless of your income. Also, your children can get free meals if your household s gross income is within the free limits on the Federal Income Eligibility Guidelines. 3. CAN FOSTER CHILDREN GET FREE MEALS? Yes, foster children that are under the legal responsibility of a foster care agency or court, are eligible for free meals. Any foster child in the household is eligible for free meals regardless of income. 4. CAN HOMELESS, RUNAWAY, AND MIGRANT CHILDREN GET FREE MEALS? Yes, children who meet the definition of homeless, runaway, or migrant qualify for free meals. If you haven t been told your children will get free meals, please call or [school, homeless liaison or migrant coordinator information] to see if they qualify. 5. WHO CAN GET REDUCED PRICE MEALS? Your children can get low cost meals if your household income is within the reduced price limits on the Federal Eligibility Income Chart, shown on this application. 6. SHOULD I FILL OUT AN APPLICATION IF I RECEIVED A LETTER THIS SCHOOL YEAR SAYING MY CHILDREN ARE APPROVED FOR FREE MEALS? Please read the letter you got carefully and follow the instructions. Call the school at [phone number] if you have questions. 7. MY CHILD S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT ANOTHER ONE? Yes. Your child s application is only good for that school year and for the first few days of this school year. You must send in a new application unless the school told you that your child is eligible for the new school year. 8. I GET WIC. CAN MY CHILD(REN) GET FREE MEALS? Children in households participating in WIC may be eligible for free or reduced price meals. Please fill out an application. 9. WILL THE INFORMATION I GIVE BE CHECKED? Yes and we may also ask you to send written proof. 10. IF I DON T QUALIFY NOW, MAY I APPLY LATER? Yes, you may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free and reduced price meals if the household income drops below the income limit. 11. WHAT IF I DISAGREE WITH THE SCHOOL S DECISION ABOUT MY APPLICATION? You should talk to school officials. You also may ask for a hearing by calling or writing to: [name, address, phone number, ]. 12. 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 U.S. citizens to qualify for free or reduced price meals. 13. WHO SHOULD I INCLUDE AS MEMBERS OF MY HOUSEHOLD? You must include all people living in your household, related or not (such as grandparents, other relatives, or friends) who share income and expenses. You must include yourself and all children living with you. If you live with other people who are economically independent (for example, people who you do not support, who do not share income with you or your children, and who pay a pro-rated share of expenses), do not include them. 14. WHAT IF MY INCOME IS NOT ALWAYS THE SAME? List the amount that you normally receive. For example, if you normally make $1000 each month, but you missed some work last month and only made $900, put down that you made $1000 per month. If you normally get overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income. 15. WE ARE IN THE MILITARY. DO WE INCLUDE OUR HOUSING ALLOWANCE AS INCOME? If you get an offbase housing allowance, it must be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. 16. MY SPOUSE IS DEPLOYED TO A COMBAT ZONE. IS HER COMBAT PAY COUNTED AS INCOME? No, if the combat pay is received in addition to her basic pay because of her deployment and it wasn t received before she was deployed, combat pay is not counted as income. Contact your school for more information. 17. MY FAMILY NEEDS MORE HELP. ARE THERE OTHER PROGRAMS WE MIGHT APPLY FOR? To find out how to apply for SNAP or other assistance benefits, contact your local assistance office or call If you have other questions or need help, call [phone number]. Si necesita ayuda, por favor llame al teléfono: [phone number]. Si vous voudriez d aide, contactez nous au numero: [phone number]. Sincerely, [signature]

17 Attachment B INSTRUCTIONS FOR APPLYING A household member is any child or adult living with you. IF YOUR HOUSEHOLD RECEIVES BENEFITS FROM SNAP OR TANF FOLLOW THESE INSTRUCTIONS: 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 SNAP or 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. IF NO ONE IN YOUR HOUSEHOLD GETS SNAP or TANF BENEFITS AND IF ANY CHILD IN YOUR HOUSEHOLD IS HOMELESS, A MIGRANT OR RUNAWAY, FOLLOW THESE INSTRUCTIONS: 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 and call [your school, homeless liaison, migrant coordinator]. 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. IF YOU ARE APPLYING FOR A FOSTER CHILD, FOLLOW THESE INSTRUCTIONS: 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 and call [your school, homeless liaison, migrant coordinator]. If not, skip this part. Continued on next page

18 Attachment B Continued from previous page IF YOU ARE APPLYING FOR A FOSTER CHILD, FOLLOW THESE INSTRUCTIONS: 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 takehome 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, TANF, 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. 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. ALL OTHER HOUSEHOLDS, INCLUDING WIC HOUSEHOLDS, FOLLOW THESE INSTRUCTIONS: 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 and call [your school, homeless liaison, migrant coordinator]. 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, TANF, 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, TANF, 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.

19 PART 1. ALL HOUSEHOLD MEMBERS Names of all household members (First, Middle Initial, Last) SY FREE AND REDUCED PRICE SCHOOL MEALS FAMILY APPLICATION 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 PART 2. BENEFITS IF ANY MEMBER OF YOUR HOUSEHOLD RECEIVES SNAP or TANF, PROVIDE THE NAME AND CASE NUMBER FOR THE PERSON WHO RECEIVES BENEFITS AND SKIP TO PART 5. IF NO ONE RECEIVES THESE BENEFITS, SKIP TO PART 3. NAME: CASE NUMBER: PART 3. IF ANY CHILD YOU ARE APPLYING FOR IS HOMELESS, MIGRANT, OR A RUNAWAY CHECK THE APPROPRIATE BOX AND CALL [your school, homeless liaison, migrant coordinator at phone #] HOMELESS MIGRANT RUNAWAY PART 4. TOTAL HOUSEHOLD GROSS INCOME. You must tell us how much and how often. 1.NAME (List only household members with 2. GROSS INCOME AND HOW OFTEN IT WAS RECEIVED Earnings From Work Pensions, retirement, Social income) before deductions Welfare, child support, alimony Security, SSI, VA benefits All Other Income (Example) Jane Smith $199.99/weekly $149.99/every other week $99.99/monthly $50.00/monthly $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / PART 5. SIGNATURE AND LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (ADULT MUST SIGN) 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 Privacy Act Statement on the back of this page.) I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted. Sign here: Print Name: Date: Phone Number: Address: City: State: Zip Code: Last four digits of Social Security Number: * * * - * * - I do not have a Social Security Number PART 6. CHILDREN S ETHNIC AND RACIAL IDENTITIES (OPTIONAL) Choose one ethnicity: Hispanic/Latino Not Hispanic/Latino Choose one or more (regardless of ethnicity): Asian American Indian or Alaska Native Black or African American White Native Hawaiian or other Pacific Islander DO NOT FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY. Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12 Total Income: Per: Week, Every 2 Weeks, Twice A Month, Month, Year Household size: Categorical Eligibility: Date Withdrawn: Eligibility: Free Reduced Denied Reason: Determining Official s Signature: Date: Confirming Official s Signature: Date: Verifying Official s Signature: Date: Revised May 2012

20 Your children may qualify for free or reduced price meals if your household income falls at or below the limits on this chart. FEDERAL ELIGIBILITY INCOME CHART For School Year Household size Yearly Monthly Weekly Each additional person: 1 20,665 1, ,991 2, ,317 2, ,643 3, ,969 4, ,295 4,775 1, ,621 5,386 1, ,947 5,996 1,384 +7, 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 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 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. 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 USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C or call toll free (866) (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer. Revised May 2012

21 Attachment C SHARING INFORMATION WITH MEDICAID/PEACHCARE Dear Parent/Guardian: If your children get free or reduced price school meals, they may also be able to get free or low-cost health insurance through Medicaid or PeachCare. Children with health insurance are more likely to get regular health care and are less likely to miss school because of sickness. Because health insurance is so important to children s well-being, the law allows us to tell Medicaid and PeachCare that your children are eligible for free or reduced price meals, unless you tell us not to. Medicaid and PeachCare only use the information to identify children who may be eligible for their programs. Program officials may contact you to offer to enroll your children. Filling out the Free and Reduced Price School Meals Application does not automatically enroll your children in health insurance. If you do not want us to share your information with Medicaid or PeachCare, fill out the form below and send in (sending in this form will not change whether your children get free or reduced price meals). No! I DO NOT want information from my Free and Reduced Price School Meals Application shared with Medicaid or PeachCare. If you checked no, fill out the form below to ensure that your information is NOT shared for the child(ren) listed below: Child's Name: School: Child's Name: School: Child's Name: School: Child's Name: School: Signature of Parent/Guardian: Date: Printed Name: Address: For more information, you may call [name] at [phone] or at [ address]. Return this form to: [address] by [date] 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 USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C or call toll free (866) (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer.

22 Attachment C Dear Parent/Guardian: SHARING INFORMATION WITH OTHER PROGRAMS To save you time and effort, the information you gave on your Free and Reduced Price School Meals Application may be shared with other programs for which your children may qualify. For the following programs, we must have your permission to share your information. Sending in this form will not change whether your children get free or reduced price meals. Yes! I DO want school officials to share information from my Free and Reduced Price School Meals Application with [name of program specific to your school]. Yes! I DO want school officials to share information from my Free and Reduced Price School Meals Application with [name of program specific to your school]. Yes! I DO want school officials to share information from my Free and Reduced Price School Meals Application with [name of program specific to your school]. If you checked yes to any or all of the boxes above, fill out the form below to ensure that your information is shared for the child(ren) listed below. Your information will be shared only with the programs you checked. Child's Name: School: Child's Name: School: Child's Name: School: Child's Name: School: Signature of Parent/Guardian: Date: Printed Name: Address: For more information, you may call [name] at [phone] or at [ address]. Return this form to: [address] by [date]. 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 USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C or call toll free (866) (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer.

23 Attachment D NOTICE OF DIRECT CERTIFICATION Dear Parent/Guardian: We want to let you know that the child(ren) listed below will receive free lunches, breakfasts, and snacks at school because they receive SNAP or TANF. Name of Child Name of School If there are other children in your household, who aren t listed above, and you would like them to receive free meals, please list their name, school, and grade information below, sign, and return this form to the School Nutrition Manager at your school. Name of Child Name of School Grade Parent or Guardian Signature: If you do not want your children to have free meals or for any questions, contact: [name] [phone number] [ address] Sincerely, [signature] Name Title Date 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 USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C or call toll free (866) (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer.

24 Attachment E NOTICE TO HOUSEHOLDS OF APPROVAL/DENIAL OF BENEFITS Dear Parent/Guardian: You applied for free or reduced-price meals for the following child(ren); Your application was: Approved for free meals Approved for reduced-price meals at $ for lunch, $ for breakfast, and $ for snacks Denied for the following reason(s): Income over the allowable amount Incomplete application because Other If you do not agree with the decision, you may discuss it with [school official s name] at [phone number] or at [ address]. If you wish to review the decision further, you have a right to a fair hearing. This can be done by calling or writing the following official: NAME: ADDRESS: PHONE NUMBER: You may reapply for benefits at any time during the school year. If you are not eligible now but have a decrease in household income, become unemployed, or have an increase in family size, you may fill out a new application at that time. Sincerely, [signature] Name Title Date 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 USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C or call toll free (866) (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer.

25 Attachment E ALTERNATIVE: PROVISION 2 PROTOTYPE LETTER FOR BASE YEAR NOTICE TO HOUSEHOLDS OF APPROVAL/DENIAL OF BENEFITS Dear Parent/Guardian: You applied for free or reduced-price meals for the following child(ren); Your application was: Approved for free meals Approved for reduced-price meals Denied for the following reason(s): Income over the allowable amount Incomplete application because. Please return a completed application or call with the missing information. Other Because [School Name] participates in Special Assistance Certification and Reimbursement Alternative- Provision II, your child(ren) will receive [breakfast, lunch, breakfast and lunch] at no charge. If you do not agree with the decision, you may discuss it with [school official s name] at [phone number] or at [ address]. If you wish to review the decision further, you have a right to a fair hearing. This can be done by calling or writing the following official: NAME: ADDRESS: PHONE NUMBER: You may reapply for benefits at any time during the school year. If you are not eligible now but have a decrease in household income, become unemployed, or have an increase in family size, you may fill out a new application at that time. Sincerely, [signature] Name Title Date 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 USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C or call toll free (866) (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer.

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