Dear Parent/Guardian:

Dear Parent/Guardian: Children need healthy meals t learn. Delaware Cmmunity Schl Crpratin ffers healthy meals every schl day. Breakfast csts $1.30; lunch csts $2.30 at the elementary level and $2.50 at the middle/high schl level. Yur children may qualify fr free meals r fr reduced price meals. Reduced price is $0.30 fr breakfast and $0.40 fr lunch. Belw are sme cmmn questins and answers t aid in the prcess f determining yur child s eligibility. 1. D I need t fill ut an applicatin fr each child? N. Use ne Free and Reduced Price Schl Meals Applicatin fr all students in yur husehld. We cannt apprve an applicatin that is nt cmplete, s be sure t fill ut all required infrmatin. Return the cmpleted applicatin t: Haley Crss 9800 N CR 200 E Muncie, IN 47303 2. Wh can get free r reduced price meals? All children in husehlds receiving benefits frm Fd Stamps (SNAP) r TANF, can get free meals regardless f yur incme. Als, if yur husehld s grss incme is within the limits n the Federal Incme Chart, yur children can get free r reduced price meals. If yu have received a Ntice f Direct Certificatin fr free meals, d nt cmplete the applicatin. But d let the schl knw if any children in yur husehld are nt listed n the Ntice f Direct Certificatin letter yu received. 3. Can fster children get free meals? Yes, fster children that are under the legal respnsibility f a fster care agency r curt, are eligible fr free meals. 4. Can hmeless, runaway, Head Start and migrant children get free meals? Yes, children wh meet the definitin f hmeless, runaway, r migrant are eligible fr free meals. If yu believe children in yur husehld meet these descriptins and haven t been tld yur children will get free meals, please call r email Dr. Darin Gullin at 765-284-5074 r email dgullin@delcmschls.rg t see if they qualify. 5. Shuld I fill ut an applicatin if I received a letter this schl year saying my children are apprved fr free meals? Please read the letter yu gt carefully and fllw the instructins. Call the schl at 765-287-8567 if yu have questins. 6. My child s applicatin was apprved last year. D I need t fill ut anther ne? Yes. Yur child s applicatin is nly gd fr that schl year. Yu must send in a new applicatin unless the schl tld yu that yur child is eligible fr the new schl year. 7. My husehld was apprved last schl year fr benefits. Hw lng d I have nce the new schl year begins t turn my applicatin in t cntinue receiving benefits? If a husehld applied last schl year, there is a 30 perating day rllver starting with the first day f schl. If a husehld des nt apply fr benefits during this 30 perating day rll-ver, the husehld will lse their benefits after the 30 days, and the husehld will g back t a paid status. 8. I get WIC. Can my children get free meals? Children in husehlds participating in WIC may be eligible fr free r reduced price meals. Please fill ut an applicatin. 9. Will the infrmatin I give be checked? Yes and we may als ask yu t send written prf. 10. If I dn t qualify nw, may I apply again later? Yes. Yu may apply at any time during the schl year. Fr example, children with a parent r guardian wh becmes unemplyed may becme eligible fr free and reduced price meals if the husehld incme drps belw the incme limit. 11. What if I disagree with the schl s decisin abut my applicatin? Yu shuld talk t the schl fficials. Yu als may ask fr a hearing by calling r writing t: Dr. Darin Gullin 7821 State Rad 3 Nrth Muncie, IN 47303 765-284-5074. 12. May I apply if smene in my husehld is nt a U. S. citizen? Yes. Yu r yur children d nt have t be U.S. citizens t qualify fr free r reduced price meals. 13. Wh shuld I include as members f my husehld? Yu must include all peple living in yur husehld, related r nt (such as grandparents, ther relatives, r friends) wh share incme and expenses. Yu must include yurself and all children living with yu. If yu live with ther peple wh are ecnmically independent (fr example, peple wh yu d nt supprt, wh d nt share incme with yu r yur children, and wh pay a pr-rate share f expenses), d nt include them. 14. What if my incme is nt always the same? List the amunt that yu nrmally receive. Fr example, if yu nrmally make $1,000 each mnth, but yu missed sme wrk last mnth and nly made $900, put dwn that yu make $1000 per mnth. If yu nrmally get vertime include it, but d nt include it if yu nly wrk vertime smetimes. If yu have lst a jb r had yur hurs r wages reduced, use yur current incme. 15. We are in the military; d we include ur husing allwance as incme? If yu get an ff-base husing allwance, it must be included as incme. Hwever, if yur husing is part f the Military Husing Privatizatin Initiative, d nt include yur husing allwance as incme. 16. My spuse is deplyed t a cmbat zne. Is her cmbat pay cunted as incme? N, if the cmbat pay is received in additin t her basic pay because f her deplyment and it wasn t received befre she was deplyed, cmbat pay is nt cunted as incme. Cntact yur child s schl fr mre infrmatin. 17. My family needs mre help. Are there ther prgrams available? T find ut hw t apply fr Fd Stamps (SNAP) r ther assistance benefits, cntact yur lcal assistance ffice. We cannt apprve an applicatin that is nt cmplete, s be sure t fill ut all required infrmatin. Return the cmpleted applicatin t: Haley Crss 9800 N CR 200 E Muncie IN 47303 hcrss@delcmschls.rg If yu have ther questins r need help, call 765-287-8567. Si necesita ayuda, pr favr llame at teléfn: 765-287-8567. Si vus vudriez d aide, cntactez nus au numer: 765-287-8567. Sincerely, Haley Crss, Fd Service Directr 2015 Parent Letter/Instructins Page 1 f 3

INSTRUCTIONS fr APPLYING A HOUSEHOLD MEMBER IS ANY CHILD OR ADULT LIVING WITH YOU. If yur husehld receives benefits frm Fd Stamps (SNAP) r TANF: Part 1: List all husehld members and the name f each child s schl schl (if knwn). Part 2: List the case number fr any husehld member (including adults) receiving Fd Stamps (SNAP) r TANF benefits. EBT, Medicaid and Hsier Healthwise numbers DO NOT qualify yu fr benefits. Part 3: Check the apprpriate bx, if any. Part 4: Skip this part. Part 5: An adult must sign the applicatin. The last fur digits f the Scial Security number are nt required. If any child in yur husehld is Migrant, Hmeless, r Runaway: Part 1: List all husehld members and the name f each child s schl schl (if knwn). Part 2: If n ne in husehld gets Fd Stamps (SNAP) r TANF benefits, skip this part. Part 3: Check the apprpriate bx and cntact the schl s hmeless liaisn r migrant crdinatr. Part 4: Cmplete nly if a child in yur husehld isn t eligible under Part 3. See instructins fr All Other Husehlds. Part 5: An adult must sign the applicatin. The last fur digits f the Scial Security number are nt required. If yu are applying fr a fster child: If all children in the husehld are fster children: Part 1: List all fster children and the schl name fr each child. Check the bx indicatin the child is a fster child. Part 2: Skip this Part Part 3: Skip this Part Part 4: Skip this Part Part 5: An adult must sign the applicatin. The last fur digits f the Scial Security number are nt required. If sme f the children in the husehld are fster children: Part 1: List all husehld members and the name f each child s schl (if knwn). Fr any persn, including children, with n incme, yu must check the N Incme bx. Check the bx if the child is a fster child. Part 2: Enter the name and case number f any husehld member wh has a valid TANF r Fd Stamp (SNAP) case number. Part 3: Check the apprpriate bx and cntact the schl s hmeless liaisn r migrant crdinatr fr any listed children wh are hmeless, migrant, r runaway. Part 4: Cmplete nly if a child in yur husehld isn t eligible under Part 1 r Part 3. See instructins fr All Other Husehlds. Part 5: An adult husehld member must sign the frm, and if incme infrmatin was prvided, the adult husehld member must prvide the last fur digits f their Scial Security Number (r mark the bx if s/he desn t have ne). All Other Husehld Types, including WIC husehlds: Part 1: List all husehld members, include everyne related r unrelated living in yur husehld (this includes yu, yur spuse, all children, grandparents, ther relatives, and unrelated peple). Use anther sheet f paper if yu have t. Enter the name f each child s schl (if knwn). Fr any persn, including children, with n incme, yu must check the N Incme bx. If any child yu are applying fr is a fster child, check the bx. Part 2: Skip this part. Part 3: If any child yu are applying fr is hmeless, migrant, r runaway, check the apprpriate bx and cntact the schl s hmeless liaisn r migrant crdinatr. Part 4: Fllw these instructins t reprt ttal husehld incme frm this mnth r last mnth. Sectin 1 Name List all husehld members with incme. Sectin 2 Grss Incme and Hw Often it was Received: Fr each husehld member listed in sectin 1, list each type f incme received fr the mnth. Yu must tell us hw ften the mney is received weekly, every ther week, twice a mnth, r mnthly. Earnings: Be sure t list the grss incme, nt the take-hme pay. Grss incme is the amunt earned befre taxes and ther deductins. Yu shuld be able t find it n yur pay stub r yur bss can tell yu. Incme received frm welfare, child supprt, and alimny: List the amunt each persn received. Incme received frm retirement benefits, Scial Security, Supplemental Security Incme (SSI), Veteran s benefits (VA benefits), and disability benefits: List the amunt each persn received. All Other Incme: List Wrker s Cmpensatin, unemplyment r strike benefits, regular cntributins frm peple wh d nt live in yur husehld, and any ther incme. D nt include benefits frm WIC, Federal educatin and fster payments received by the family frm the placing agency. Fr ONLY the self-emplyed, under Earnings frm 2015 Parent Letter/Instructins Page 2 f 3

Wrk, reprt incme after expenses. This is fr yur business, farm, r rental prperty. If yu are in the Military Privatized Husing Initiative r get cmbat pay, d nt include these allwances as the incme. Part 5: Adult husehld member must sign the frm and list the last fur digits f their Scial Security Number (r mark the bx if s/he desn t have ne). FEDERAL INCOME CHART FOR SCHOOL YEAR 2014-2015 Husehld Size Yearly Mnthly Twice Per Mnth Every Tw Weeks 1 21,590 1,800 900 831 416 Yur children may qualify fr free r reduced price meals if yur husehld incme falls within the limits n this chart. 2 29,101 2,426 1,213 1,120 560 3 36,612 3,051 1,526 1,409 705 4 44,123 3,677 1,839 1,698 849 5 51,634 4,303 2,152 1,986 993 6 59,145 4,929 2,465 2,275 1,138 7 66,656 5,555 2,778 2,564 1,282 8 74,167 6,181 3,091 2,853 1,427 Fr each additinal persn: +7,511 +626 +313 +289 +145 Other Benefits: Put a checkmark where yu want the infrmatin released. By signing this sectin yu will allw the schl t release infrmatin that shws yu have applied fr free r reduced price benefits under the NSLP. The infrmatin will nly be used fr the prgrams yu have marked n the applicatin. Textbk Assistance Yu must answer this questin and sign, in rder t receive textbk assistance. Yu are nt required t answer this questin t receive meal benefits. PLEASE NOTE: Fr Textbk Assistance, these are specific things that yu must cmplete in additin t the required items fr meal benefits: Living with parent/caretaker relative The definitin f a caretaker relative is a relative, either by bld r by law, wh lives with the child and exercises parental respnsibility [care and cntrl] in the absence f the child s parent. Examples include, but are nt limited t: Grandparents, Aunts, Uncles, Cusins, Step-Parents, and Adult Siblings. Grade Check if yu are applying fr textbk assistance and sign under Other Benefits. Yur applicatin must cntain 2 signatures fr meals and textbks. Hsier Healthwise Yur child(ren) may qualify fr free r lw-cst health insurance under Medicaid r Hsier Healthwise. If yu DO WANT this infrmatin released fr the purpse f Hsier Healthwise, please sign. Fr mre infrmatin abut Hsier Healthwise health insurance, call 1-800-889-9949. 2015 Parent Letter/Instructins Page 3 f 3

Every 2 wks. Twice A Mnth Mnthly Every 2 Wks. Twice A Mnth Mnthly Every 2 Wks. Twice A Mnth Mnthly Every 2 Wks Twice A Mnth Mnthly Prescribed by State Bard f Accunts Schl Frm N. 521 / 2014 Delaware Cmmunity Schl Crpratin 1875 SCHOOL CORPORATION CORP. NUMBER APPLICATION FOR FREE OR REDUCED PRICE MEALS AND OTHER BENEFITS Part 1. Names f all husehld members (First, Middle Initial, Last) Effective July 1, 2005 - One Applicatin per Husehld Only fr Check if living Only fr with parent r Name f each child s schl caretaker relative Only fr Grade Only fr Birthdate Only fr Check if a Fster child Check if n incme If ALL children listed abve are fster children, skip t Part 5 and sign. Part 2. If any member f yur husehld (student, adult r nn-student) has a valid Fd Stamp (SNAP) r TANF case number, please prvide the name f the persn wh receives benefits, check the bx indicating the benefit prgram, and enter the case number, then skip t Part 5. If n ne receives these benefits, skip t Part 3. Name: Fd Stamp TANF Case Number: / / / / / / / / / Part 3. If any child yu are applying fr is migrant, hmeless, r runaway, check the apprpriate bx and call Dr. Darin Gullin at 765-284-5074. Migrant Hmeless Runaway Part 4. Sectin 2 TOTAL HOUSEHOLD GROSS INCOME (BEFORE DEDUCTIONS). LIST ALL INCOME ON THE SAME LINE AS THE PERSON WHO RECEIVES IT. CHECK THE BOX FOR HOW OFTEN IT IS RECEIVED. RECORD EACH INCOME ONLY ONCE. GROSS INCOME and HOW OFTEN IT WAS RECEIVED Examples: $100 / mnthly r $100 / every 2 weeks r $100 / twice a mnth r $100 / weekly Sectin 1 NAME (List ONLY husehld members with incme) Earnings frm Wrk Befre Deductins Welfare, Child Supprt, Alimny Scial Security, SSI, VA, Retirement Benefits All Other Incme such as Unemplyment Example: Jane Smith $ 200 $ 150 $ 100 $ 50 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Part 5. SIGNATURE: An adult husehld member must sign the applicatin. If Part 4 is cmpleted, the adult signing the frm als must list the last fur digits f his r her Scial Security Number r mark the N Scial Security Number bx. (See Statement n the back f this page). I certify (prmise) that all infrmatin n this applicatin is true and that all incme is reprted. I understand that the schl will get Federal funds based n the infrmatin I give. I understand that schl fficials may verify (check) the infrmatin. I understand that if I purpsely give false infrmatin, my children may lse meal benefits, and I may be prsecuted. I understand my child s eligibility status may be shared as allwed by law. X *** - ** - N Scial Signature f Adult Husehld Member Scial Security Number Security Number Hme Telephne # / Wrk Telephne # Printed Name f Adult Husehld Member Date Signed Hme Address/Apt # Zip Cde Email Address Part 6. OTHER BENEFITS This sectin des nt need t be cmpleted t receive free r reduced price meal benefits. I certify that I am the parent/guardian f the child(ren) fr whm applicatin is being made. D yu want t receive TEXTBOOK My signature belw authrizes the release f infrmatin n this applicatin fr textbk ASSISTANCE? assistance. I give up my right f cnfidentiality fr this purpse nly. This applicatin infrmatin will be shared with the Indiana Family and Scial Services Administratin YES If, YES, SIGN TO THE RIGHT pursuant t I.C. 20-33-5-2 and I.C. 12-14-28-2, slely fr purpses f cmplying with 45 NO C.F.R. PARTS 260 AND 265. X SIGNATURE OF PARENT/GUARDIAN DATE SCHOOL USE ONLY: Apprved Denied Nt Applicable Page 1 f 2 Prgram Year 2015

Part 6. OTHER BENEFITS (Cntinued frm Page 1) This applicatin infrmatin may be shared with the Family and Scial Services Administratin fr the purpse f identifying children wh may qualify fr free r lw-cst health insurance under Medicaid r Hsier Healthwise. If yu want the applicatin infrmatin shared fr this purpse, please sign belw. I certify I am the parent/guardian f the child(ren) fr whm applicatin is being made. I authrize the release f infrmatin fr this purpse. X Fr infrmatin abut Hsier Healthwise SIGNATURE OF PARENT/GUARDIAN DATE health insurance, call 1-800-889-9949. Part 7. RACE AND ETHNICITY: Optinal - Yu are nt required t answer this questin. N child will be discriminated against because f race, clr, sex, natinal rigin, age, r disability. Mark ne r mre (regardless f ethnicity): Asian Black r African American American Indian r Alaska Native Native Hawaiian r Other Pacific Islander White Mark ne ethnicity: Hispanic r Latin Nt Hispanic r Latin Use f Infrmatin Statement: This explains hw we will use the infrmatin yu give us. The Richard B. Russell Natinal Schl Lunch Act requires the infrmatin n this applicatin. Yu d nt have t give the infrmatin, but if yu d nt, we cannt apprve yur child fr free r reduced price meals. Yu must include the last fur digits f the scial security number f the adult husehld member wh signs the applicatin. The last fur digits f the scial security number is nt required when yu apply n behalf f a fster child r yu list a Supplemental Nutritin Assistance Prgram (SNAP), Temprary Assistance fr Needy Families (TANF) Prgram r Fd Distributin Prgram n Indian Reservatins (FDPIR) case number r ther FDPIR identifier fr yur child r when yu indicate that the adult husehld member signing the applicatin des nt have a scial security number. We will use yur infrmatin t determine if yur child is eligible fr free r reduced price meals, and fr administratin and enfrcement f the lunch and breakfast prgrams. We MAY share yur eligibility infrmatin with educatin, health, and nutritin prgrams t help them evaluate, fund, r determine benefits fr their prgrams, auditrs fr prgram reviews, and law enfrcement fficials t help them lk int vilatins f prgram rules. Nn-discriminatin Statement: This explains what t d if yu believe yu have been treated unfairly. The U.S. Department f Agriculture prhibits discriminatin against its custmers, emplyees, and applicants fr emplyment n the bases f race, clr, natinal rigin, age, disability, sex, gender identity, religin, reprisal, and where applicable, plitical beliefs, marital status, familial r parental status, sexual rientatin, r all r part f an individual's incme is derived frm any public assistance prgram, r prtected genetic infrmatin in emplyment r in any prgram r activity cnducted r funded by the Department. (Nt all prhibited bases will apply t all prgrams and/r emplyment activities.) If yu wish t file a Civil Rights prgram cmplaint f discriminatin, cmplete the USDA Prgram Discriminatin Cmplaint Frm, fund nline at http://www.ascr.usda.gv/cmplaint_filing_cust.html, r at any USDA ffice, r call (866) 632-9992 t request the frm. Yu may als write a letter cntaining all f the infrmatin requested in the frm. Send yur cmpleted cmplaint frm r letter t us by mail at U.S. Department f Agriculture, Directr, Office f Adjudicatin, 1400 Independence Avenue, S.W., Washingtn, D.C. 20250-9410, by fax (202) 690-7442 r email at prgram.intake@usda.gv. Individuals wh are deaf, hard f hearing r have speech disabilities may cntact USDA thrugh the Federal Relay Service at (800) 877-8339; r (800) 845-6136 (Spanish). USDA is an equal pprtunity prvider and emplyer. FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE INCOME CONVERSION t YEARLY: WEEKLY INCOME X 52 EVERY 2 WEEKS X 26 TWICE A MONTH X 24 MONTHLY INCOME X 12 ELIGIBILITY DETERMINATION Incme Eligibility: Ttal Husehld Size: Ttal Incme:$ per: Every 2 Weeks Mnthly Twice a Mnth Yearly OR Categrical Eligibility: Fd Stamps TANF Migrant Hmeless Runaway Fster Eligibility Determinatin: Apprved Free Apprved Reduced price Denied Reasn fr Denial: Incme T High Incmplete Applicatin Other(Reasn) Signature f Determining Official: Date: Date Withdrawn: VERIFICATION Cnfirmatin Review Official: Date Verificatin Ntice Sent: Date Respnse Due frm Husehlds: Date Secnd Ntice Sent (r N/A): Apprval Based On: Fd Stamps / TANF Case Number Husehld Size and Incme Other Verificatin Results: N Change Free t Reduced Free t Paid Reduced t Free Reduced t Paid Reasn fr Change: Incme: Husehld Size: Change in Fd Stamps /TANF Did nt respnd Other: Date Ntice f Change Sent: Date Change Made: Date Hearing Requested: Hearing Decisin: Verifying Official's Signature: Date: Page 2 f 2 Prgram Year 2015