TO: Sponsors
of School Nutrition Programs
FROM: Food and
Nutrition Service
DATE: June 8,
2011
SUBJECT: 2011-12
Household Income Guidelines and Application for Educational Benefits
This information applies to all Local Educational Agencies
(LEA) that participate in School Nutrition Programs, except the following types of LEAs
that will not collect Applications
for Educational Benefits during school year 2011-12:
(1) Residential child care institutions
that have an approved resident income policy instead of collecting meal
applications, and have no day-only students.
(2) Nonpublic schools that claim
reimbursement for all meal services at all sites using Provision 2 or 3
procedures and are not conducting a Provision 2 or 3 base year for any site.
Changes for School
Year 2011-12
The following changes to school meal approval procedures have
been implemented as required by the Healthy, Hunger-Free Kids Act of 2010:
-
Categorical Eligibility
for foster children: Children identified by the household as foster
children (a welfare agency or court has legal responsibility for the child) are
now categorically eligible for free school meals. The Application for
Educational Benefits no longer has a separate section for foster children and
no longer requires the household to report the amount of “personal use income”
to the foster child. The household only needs to identify each foster child by
checking a box.
Individual
applications are no longer needed for foster children; all children in a
household, including foster children, should be included on one application. If
there are both foster children and other children in the same household, the
eligibility of the children who are not foster children depends on the family
size/income of the whole household including the foster children. For more
information about approving “Household Size/Income + Foster” applications,
refer to the attached SNP Procedure of
Approval/Denial – Applications for Educational Benefits.
-
Certification of
foster children: MDE is working with the Minnesota Department of Human
Services to establish a pilot program for certification of foster children to
schools for school meal benefits, without households needing to submit an
Application for Educational Benefits for the foster children. Beginning in July
2011, county foster care workers will send a completed Certification of Foster Care Status for School Lunch or Food Program
form to a foster child’s school at the time that the child is placed in foster
care. The form identifies the foster child and provides official certification
from the county that the child is in foster care.
This project will be evaluated during school year 2011-12 to
determine the extent to which foster care certification has certified
additional children for meal benefits.
-
Last four digits
of Social Security Number: Section 6 of the Application for Educational
Benefits has been revised to require only the last four digits of the signer’s
Social Security number (SSN). If section 4 of the application has been
completed (household income information), the signer must either provide the
last four digits of their SSN or check the box to indicate that they do not
have an SSN.
Distribution of
Application Packets for School Year 2011-12
An LEA must inform all households about school meal benefits
by the beginning of each school year. Application materials for school year 2011-12
should be distributed within the
four weeks prior to the first day of school. Application packets may not be
distributed before July 1, 2011, the date that the income guidelines are
effective; the only exception is that year-round schools operating in July may
distribute applications in June.
Households may not be required
to complete Applications for Educational Benefits. LEAs may consider taking
additional steps to facilitate the return of applications from households, such
as providing return envelopes in a mailing.
The attached materials must be sent to households to notify
them about school meal benefits:
-
Household letter
about school meal benefits (one page - reproduce on school letterhead and insert
meal prices and other information)
-
Instructions for
completing the Application for Educational
Benefits form (one page – may be copied on the reverse side of the
household letter)
-
Application for
Educational Benefits form (the back page with information about data
privacy and civil rights must be included)
Carryover of Meal Benefits from Previous Year: School meal
benefits that were approved in school year 2010-11 (from either application or
direct certification) must be carried over into the beginning of school year
2011-12. Meal benefits must be carried over for the first 30 operating school
days of school year 2011-12, or up to the date that a student is approved for
school year 2011-12 meal benefits (from application or direct certification),
whichever date comes first.
Annual Requirement to Notify about State Health Programs: Public school districts and charter schools
may use their mailing about school meal benefits to also notify households about
state of Minnesota
health care programs as required by subdivision 6 of Minnesota Statutes section
256.962. View Statute.
The memorandum and flyer for Minnesota Health Care Programs Notification are available in
English and Spanish. View
documents on “Minnesota Health Care Programs” on the Minnesota Department of
Education (MDE) website.
Application
Approval
School meal benefits are approved for the whole school year
unless an LEA approves an application only on a temporary basis. Once approved
for the year, meal benefits are terminated or changed only when required due to
verification or administrative review, or terminated at the request of a
household. Households are not required
to notify their LEA of any change in household circumstances during the year.
References for reviewing and approving Applications for Educational Benefits:
-
Attached Procedure
for Approval/Denial – Applications for Educational Benefits.
-
Eligibility
Guidance for School Meals manual. View
manual on USDA website.
Conversion of Incomes to Annual Income: When an application has
incomes that are paid at different frequencies, the LEA must convert each
income to an annual income and then add the annual incomes together. To convert to annual income: multiply a
weekly income by 52, a bi-weekly income (every other week) by 26, a
twice-per-month income by 24 or a monthly income by 12.
Example: A household reports incomes of $500 received every two
weeks and $1,000 received monthly. Since the incomes are paid at different
frequencies, they must be converted to annual incomes in order to add them
together: $500 bi-weekly income x 26 = $13,000 annual income, and $1000 monthly
income x 12 = $12,000 annual income. The two annual incomes are then added
together for a total annual household
income of $25,000.
Categorical Eligibility: If a household reports a case number
that appears valid, all of the students in the household are approved for free
meals based on categorical eligibility.
A case number may be provided from any of these three programs:
- Minnesota Family Investment Program (MFIP).
-
Food Support (This is the program that used to be called “Food Stamps.” At the
national level it is referred to as the Special Nutrition Assistance Program or
SNAP).
- Food Distribution Program on Indian Reservations (FDPIR).
Households receiving Medical Assistance benefits only are not categorically eligible – they must
complete an application based on household income.
Directly Certified Students (Public Schools): Applications
should not be sent to households with
students who have been directly certified for free school meals based on public
assistance data sent to the LEA from MDE. Direct certification is based on a
household’s receipt of Minnesota Family Investment Program (MFIP) or Food Support
(previously Food Stamp) benefits. If one child in a household has been directly
certified, then all children in the household are considered directly certified
for free school meals.
Application for Student from Residential Child Care Institution: When
a student living in a residential child care institution (RCCI), for example a
group home, attends an LEA, the RCCI
director should complete the meal application for the
student and indicate that the application is for a student in residential care.
The completed application must identify the child and list any regular income to
the student in Section 2, and the RCCI director must sign in Section 6 (Social
Security number not needed).
Consent to Release
Data for Health Insurance Purposes
The state of Minnesota continues its efforts to notify
eligible families about the availability of state-administered children’s
health insurance programs such as MinnesotaCare. Section 5 of the
Application for Educational Benefits records whether
households that are approved for meal benefits have declined to share their
eligibility information with health insurance programs. The section uses a
“negative check-off” format which allows the household’s school meals
eligibility information to be shared with the health insurance programs unless
the household has checked one or both boxes to indicate that information may
not be shared. Public schools annually report the data in MARSS on whether
students’ information may be shared for this purpose.
Civil Rights Survey
LEAs must maintain documentation of the race and ethnicity
of all students for federal civil rights purposes. When the Civil Rights Survey
section is not completed by the household, the school must identify the race and
ethnicity for the household.
Nondiscrimination
Statement
The nondiscrimination statement and procedure for filing a
complaint on the back page of the Application for Educational
Benefits has
been updated with the most recent version available from USDA.
Translations
Translations of a 2011-12 application form, based on the
USDA prototype meal forms in Spanish, Hmong, and Somali, will be posted to the
MDE website by July 2011. A listserv message will be sent when the translated
forms have been posted.
USDA also provides translations of the generic school meal application
in 22 other languages. View list of translated
application packets To use a USDA translation, first select the link for
the desired language and then select the following parts of the translated
document:
-
Household letter (2 pages)
-
Instructions for Applying (2 pages)
-
Application (3 pages) The current household income
guidelines must be copied onto the last page of the application.
-
Sharing Information with Medicaid/SCHIP (1 page)
The English language version of the USDA documents is also
available from the link provided above.
Notification of
Approval or Denial of Benefits
The template letter for notifying households of approval or
denial of school meal benefits is attached.
MARSS Economic Indicator
(Public Schools)
The “economic indicator” reported annually by public schools
on student MARSS records is based on student eligibility for school meal
benefits. The economic indicator must be based only on school meal benefits
that have been approved for the new school year, that is, applications and direct
certifications that have been received for school year 2011-12. The Economic
Indicator for school year 2011-12 may not
be based on eligibility for meal benefits that has been carried over from the
previous school year for the first 30 operating days of school year 2011-12.
Verification of
Information Provided on Applications
Each fall an LEA must verify a percentage (usually three
percent) of approved Applications for Educational Benefits. In addition, any
application may be verified “for cause.” The memorandum on verification
requirements for school year 2011-12 will be issued in August 2011.
Attachments
For internal use by LEA:
-
2011-12 Household
Income Guidelines for free and reduced-price meals
-
Procedure for
Approval/Denial - Applications for Educational Benefits
For distribution to households:
-
Household letter
(one page)
-
Instructions
for completing Application for Educational Benefits (one page - may be copied
on the back of household letter)
-
Application for
Educational Benefits (2 pages)
For distribution to households after application has been
reviewed:
-
Notice of approval/denial
If you have any questions about this information, contact
Food and Nutrition Service at 651-582-8526, 1-800-366-8922 or e-mail fns@state.mn.us.
|
School
Nutrition Programs
Household
Income Guidelines for School Year 2011-12
Effective
July 1, 2011 through June 30, 2012
|
|
HOUSEHOLD
SIZE
|
FREQUENCY
OF INCOME
|
FREE
MEALS
$
|
REDUCED-PRICE MEALS
$
|
PAID
MEALS
$
|
|
1
|
Weekly
Bi-Weekly
2 X Month
Monthly
Yearly
|
0 – 273
0 – 545
0 – 590
0 – 1,180
0 – 14,157
|
274 – 388
546 – 775
591 – 840
1,181 – 1,679
14,158 – 20,147
|
389
776
841
1,680
20,148
|
or more
|
|
2
|
Weekly
Bi-Weekly
2 X Month
Monthly
Yearly
|
0 – 368
0 – 736
0 – 797
0 – 1,594
0 – 19,123
|
369 – 524
737 – 1,047
798 – 1,134
1,595 – 2,268
19,124 – 27,214
|
525
1,048
1,135
2,269
27,215
|
or more
|
|
3
|
Weekly
Bi-Weekly
2 X Month
Monthly
Yearly
|
0 – 464
0 – 927
0 – 1,004
0 – 2,008
0 – 24,089
|
465 – 660
928 – 1,319
1,005 – 1,429
2,009 – 2,857
24,090 – 34,281
|
661
1,320
1,430
2,858
34,282
|
or more
|
|
4
|
Weekly
Bi-Weekly
2 X Month
Monthly
Yearly
|
0 – 559
0 – 1,118
0 – 1,211
0 – 2,422
0 – 29,055
|
560 – 796
1,119 – 1,591
1,212– 1,723
2,423 – 3,446
29,056 – 41,348
|
797
1,592
1,724
3,447
41,349
|
or more
|
|
5
|
Weekly
Bi-Weekly
2 X Month
Monthly
Yearly
|
0 – 655
0 – 1,309
0 – 1,418
0 – 2,836
0 – 34,021
|
656 – 932
1,310 – 1,863
1,419 – 2,018
2,837 – 4,035
34,022 – 48,415
|
933
1,864
2,019
4,036
48,416
|
or more
|
|
6
|
Weekly
Bi-Weekly
2 X Month
Monthly
Yearly
|
0 – 750
0 – 1,500
0 – 1,625
0 – 3,249
0 – 38,987
|
751 – 1,067
1,501 – 2,134
1,626 – 2,312
3,250 – 4,624
38,988 – 55,482
|
1,068
2,135
2,313
4,625
55,483
|
or more
|
|
7
|
Weekly
Bi-Weekly
2 X Month
Monthly
Yearly
|
0 – 846
0 – 1,691
0 – 1,832
0 – 3,663
0 – 43,953
|
847 – 1,203
1,692 – 2,406
1,833 – 2,607
3,664– 5,213
43,954 – 62,549
|
1,204
2,407
2,608
5,214
62,550
|
or more
|
|
8*
|
Weekly
Bi-Weekly
2 X Month
Monthly
Yearly
|
0 – 941
0 – 1,882
0 – 2,039
0 – 4,077
0 – 48,919
|
942 – 1,339
1,883 – 2,678
2,0040– 2,901
4,078 – 5,802
48,920– 69,616
|
1,340
2,679
2,902
5,803
69,617
|
or more
|
|
*Additional household members. For free meals add for each additional
household member: $96 weekly, $191
bi-weekly, $207 2 X month, $414 monthly, or $4,966 yearly. For reduced-price meals add for each additional
household member: $136 weekly, $272 bi-weekly, $295 2 X month, $589 monthly,
or $7,067 yearly.
|
Attachment – for
School Use Only
|
|
|
|
|
|
|
|
Attachment – for
School Use Only
|
|
|
|
School
Nutrition Programs
Procedure
for Approval/Denial – Applications for Educational Benefits
|
|
These are the main steps for a school food authority to
review and approve or deny Applications for Educational Benefits.
Step Determine the type of application
The minimum information required on an application depends
on the type of application. There are four types of applications, depending on
which sections of the application have been completed by the household:
a. Case Number application Case number
provided in Section 3. (If case number is provided, disregard any household
size/income information provided in Section 4.)
b. Foster Children Only application All household children who
need to be approved for meal benefits are foster children.
c. Household Size/Income Only application
Household size/income provided in Section 4, no foster children in Section 2,
and no case number in Section 3.
d. Combination – Household Size/Income +
Foster application (Some, but not all, of the children in Section 2 are
foster children; household size/income information is provided in Section 4.)
Step ‚
Check for complete application and review information
Based on the type of application determined
in step 1, review the application to determine whether it is complete and
whether the students can be approved for meal benefits.
Note: Sections 1 and 5 on the
application do not have to be completed, regardless of the type of application.
a.
Case Number
application
All household children are categorically eligible for free
meals if a case number is provided from the Minnesota Family Investment Program
(MFIP), Food Support (SNAP) or Food Distribution on Indian Reservations
(FDPIR). A case number application is
complete if the household has provided:
Section 2 – Children’s names
Section 3 – Case number
- MFIP
and Food Support (SNAP) case numbers are four to eight digits (usually seven or
eight digits) with no letters.
- FDPIR
uses Social Security number for case number.
- A
Medical Assistance case number does not
qualify.
- Disregard
any income information provided in section 4 of the application.
Section 6 – Signature of an adult
household member (Social Security number not needed).
If any required information is missing, return the application
to the household with a notification of denial letter that explains what
information is missing. In the approval section at the bottom of the
application, check the box that the application was incomplete and sign and
date.
If the application is complete, approve the students
for free meals. In the approval box at the bottom of the application, check the
box indicating that there is a case number, and sign and date the application. Proceed
to step 3.
b.
Foster
Children Only application
Foster children are categorically eligible for free school
meals. An application for one or more foster children only (see section d below
if there are any other enrolled students in the household in addition to the foster
children) is complete if the household has provided:
Section 2 – Children’s names and
boxes are checked to indicate they are foster children.
Section 6 – Signature of an adult
household member (Social Security number not needed).
If any required information is missing, return the
application to the household with a notification of denial letter that explains
what information is missing. In the approval section at the bottom of the
application, check the box that the application was incomplete and sign and
date.
If the application is complete, approve the students for
free meals. In the approval box at the bottom of the application, check the box
for foster children and sign and date the application. Proceed to step 3.
c.
Household
Size/Income Only application
If the application is completed with household size/income
information only (no case number and no foster children), the application is
complete if the household has provided:
Section 2 – Children’s names.
Section 4 – Household size/income for
each adult (or indication of “no income”).
Section 6 – Signature of an adult
household member and the last four digits of their Social Security number (SSN)
or an indication that the signer does not have an SSN.
If any required information is missing, return the
application to the household with a notification of denial letter that explains
what information is missing.
If the application is complete:
-
Determine total household members (number of people listed
in sections 2 and 4) and record in the approval section.
-
Determine the total income* for the household from
section 4 (also include any regular incomes to children reported in section 2)
and record the total income in the approval section. Compare the household
income to the maximum income for a household of that size in the USDA household
income eligibility guidelines. Approve for free meals, or reduced-price meals,
or deny meal benefits.
-
In the approval box at the bottom of the application, indicate
the status (approved for free or reduced-price, or denied), and sign and date.
-
Proceed to step 3.
* If all household incomes are reported at the
same frequency (all incomes are weekly, or all incomes are monthly, etc.), then
add all income amounts together for total household income.
If household
incomes are reported at different frequencies, convert all income amounts to
the same frequency and then add all income amounts together for total household
income. To convert incomes to an annual income, multiply a weekly income by 52,
a bi-weekly income by 26, a twice-per-month income by 24, or a monthly income
by 12.
d.
Combination
– Household Size/Income + Foster Children application
If the household has a combination of some foster children
and some other children (who may be approved based on total household
size/income), the eligibility of the two groups of children must be determined
separately. The foster children are categorically eligible for free school
meals and the eligibility of the other children depends on the total household
size/income.
Note that when there are foster children and other children
on the same application, there may be different eligibility results for each
group. For example, foster children might be approved for free meals, but other
children in the household approved for reduced-price meals or denied meal
benefits.
Foster Children
Children who are indicated in section 2 of the application to
be foster children are categorically eligible for free meals. Approve these
children for free meals, or return the application to the household if any
information is missing, and document the status of foster children in the
approval section of the application, as described above in “Foster Children
Only application.”
Other Children
Other children in the same household, who are not indicated to
be foster children, are eligible for free or reduced-price meals if they
qualify based on the total household size (including
the foster children) and total household income (not including foster care payments). Approve or deny these children
for free or reduced-price meals, or return the application if information is
missing, and document the status of the other children in the approval section
of the application, as described in the section above on “Household Size/Income
Only application.”
Step ƒ Notify household
Send a notice of approval or denial to household. In
situations where there is more than one eligibility result for a household (foster
children approved for free meals and other children approved for reduced-price
meals or denied), multiple notification letters may be sent to the
household.
Summary – Information
Required for a Complete
Application for Educational Benefits
|
Sections of Application for Educational Benefits
|
Required Information for
|
|
Categorical Eligibility
based on Case Number 1
|
Categorical Eligibility for Foster
Child 2
|
Approval based on Family Size/ Income 2
|
|
1
|
Check box (not
required to be completed)
|
|
|
|
|
2
|
Names of children
|
ü
|
ü
|
ü
|
|
Box checked to
indicate foster status
|
|
ü
|
|
|
Regular earnings of children,
if any
|
|
|
ü
|
|
3
|
Case number
|
ü
|
|
|
|
4
|
Names and incomes of
adults
|
|
|
ü
|
|
5
|
Check boxes (not
required to be completed)
|
|
|
|
|
6
|
Signature of adult household member
|
ü
|
ü
|
ü
|
|
Last four digits of
signer’s Social Security number, or indication of no SSN
|
|
|
ü
|
1 If a
case number is provided, all children in
the household are approved for free meals based on the case number and the
signature of an adult household member. Any income information provided by the
household is not considered. The case number must be from the Minnesota Family
Investment Program (MFIP), Food Support (SNAP), or Food Distribution on Indian
Reservations (FDPIR). MFIP and Food Support case numbers are four to eight (usually
seven or eight) digits with no letters. FDPIR uses the Social Security number
for case number. A Medical Assistance case number does not qualify.
2 If an
application has some children whose approval is based on family size/income,
and others who are foster children, approval is separate for the foster children
and the other children. For example, an application could be approved for a
foster child, but be missing family size/income information that is needed to
approve meal benefits for the other children in the household.
[Print on School District Letterhead]
Dear Parent/Guardian:
Our school provides healthy meals
each day. Breakfast costs $ ; lunch
costs $ .
Your children may qualify for free or
reduced-price meals. Reduced price is [$
] for lunch. “Reduced-price” breakfasts are served at no charge. To
apply for free or reduced-price school meals, complete the enclosed Application
for Educational Benefits following the instructions. A new application must be
submitted each year. Your application also helps our school qualify for
additional education funds and discounts.
Return your completed Application for
Educational Benefits to:
Who
can get free or reduced-price meals? Children
in households participating in Food Support (SNAP), Minnesota Family Investment
Program (MFIP), or Food Distribution Program on Indian Reservations (FDPIR) and
foster children can get free school meals without reporting household income.
Also, children can get free or reduced-price meals if their household income is
within the maximum income shown for the household size. An application must be
submitted each school year.
Can foster children get free meals? Yes, foster children who are the legal responsibility
of a foster care agency or court are eligible for free meals regardless of
household income.
I get WIC. Can my children get free meals? Children in households participating in WIC may be
eligible for free or reduced-price meals. Please fill out an application.
May I apply if someone in
my household is not a U.S. citizen? Yes.
You or your children do not have to be U.S. citizens for your children to
qualify for free or reduced-price meals.
If I don’t qualify now,
may I apply later? Yes. You may apply
at any time during the school year if your income goes down, household size
goes up, or if you start getting Food Support (SNAP), MFIP, or FDPIR benefits.
Who should I include as
members of my household? Include
yourself and all other people living in the household, related or not (such as
grandparents, other relatives or friends). Include a household member who is
temporarily away, such as a college student. Do not include a person who is
economically independent and pays their full pro-rated share of all expenses.
What if my income is not always the same? List the amount that you normally get. If you normally
get overtime, include it, but not if you get it only sometimes.
Are military housing and supplemental allowances
counted as income? Do not include any
housing allowance from the Military Housing Privatization Initiative or a
Family Subsistence Supplemental Allowance. Include the portion of a deployed
service member’s income that is made available to the household, except do not
include combat pay or Deployment Extension Incentive Pay.
How will the information I provide be kept? Information you provide on the form, and your child’s
approval for school meal benefits, will be protected as private data. See the
back page of the Application for Educational Benefits for more information.
Will the information I
give be checked? Yes and we may also ask
you to send written proof.
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.
Do I need to notify school officials if my income
increases or my household size decreases after I have qualified for free or
reduced-price meals? No. Approval for
free or reduced-price meals is good for the school year unless the household has
received a temporary approval for school meal benefits.
If you have other questions
or need help, call [phone number].
Sincerely, [signature]
Instructions for
Completing the Application for Educational
Benefits
Complete
an application if one or more of the following apply to your household:
−
Any member of the
household currently participates in any of these three programs: Minnesota Family Investment Program
(MFIP), Food Support (SNAP), or Food
Distribution Program on Indian Reservations (FDPIR).
−
One or more children
in the household are foster children
(a welfare agency or court has legal responsibility for the child).
−
Total household income (gross earnings, not
take-home pay) is within these guidelines:
|
Household Size
|
$ Per
Year
|
$ Per Month
|
$ Twice Per Month
|
$ Per 2 Weeks
|
$ Per Week
|
|
1
|
20,147
|
1,679
|
840
|
775
|
388
|
|
2
|
27,214
|
2,268
|
1,134
|
1,047
|
524
|
|
3
|
34,281
|
2,857
|
1,429
|
1,319
|
660
|
|
4
|
41,348
|
3,446
|
1,723
|
1,591
|
796
|
|
5
|
48,415
|
4,035
|
2,018
|
1,863
|
932
|
|
6
|
55,482
|
4,624
|
2,312
|
2,134
|
1,067
|
|
7
|
62,549
|
5,213
|
2,607
|
2,406
|
1,203
|
|
8
|
69,616
|
5,802
|
2,901
|
2,678
|
1,339
|
|
For each additional household member add:
|
7,067
|
589
|
295
|
272
|
136
|
Section 1 Check
the box if this is the first time that you have applied for meal benefits for
any of your children at this school district or nonpublic school.
Section 2
List all children in the household, including foster children, and provide the
requested information for each child. List any regular incomes to children such
as SSI payments or regular earnings. Do not list occasional earnings like
babysitting.
Foster children:
check the “foster child” box for each child who is a foster child (a welfare
agency or court has legal responsibility for the child). If all children who
need to be approved for school meal benefits are foster children, skip sections
3 and 4.
Section 3 If
any member of the household receives public assistance from any of the
following three programs, write in the person’s name and case number: Minnesota Family Investment Program
(MFIP), Food Support (SNAP), or Food Distribution Program on Indian
Reservations (FDPIR). If section 3 is completed, skip section 4. A Medical
Assistance number does not qualify
for this purpose.
Section 4
Write in all adult household members and all incomes. Include all adult persons
who live in the household whether related or not. Also include any persons who
are temporarily away, such as a student away at college.
For earnings, list gross income before taxes and other
deductions, not take home pay. You should be able to find your gross income
on your pay stub. For farm/self-employment
income only, list net income after business expenses. Write in how often
each income is received: Weekly (W), Bi-Weekly (every other month) (BW), Twice
per Month (TM), or Monthly (M). Do not write
in an hourly wage.
Examples of “other income” to
include in the last column are farm or self-employment income, Veterans (VA) benefits,
and disability benefits.
Do not include as income: foster care payments, federal education benefits, or
assistance provided by MFIP, Food Support (SNAP), WIC or FDPIR. Military: Do not include income from the Military
Privatized Housing Initiative or combat pay.
Section 5 Leave
these boxes blank if you want to share your school meal eligibility status with
these health benefit/insurance programs. Check the boxes if you do not want to
share your eligibility status with these programs.
Section 6 The
form must be signed by an adult household member. If section 4 of the
application has been completed, the signer must provide the last four digits of
their Social Security number unless they indicate that they do not have a Social
Security number. Provide address and phone number to assist in processing your
application.
Also please provide voluntary
racial/ethnic information requested on the back page of the form.
1. o Check
here if this is the first school meal application at this school district or nonpublic
school for any child listed below.
3.
Benefits (if applicable)
If
any household member receives benefits from a program listed below, check
the applicable box and write in the name of the person receiving benefits
and their case number. Skip section 4.
________________ ______________
Name Case Number
*
Minnesota Family Investment Program (MFIP)
*
Food Support (SNAP)
* Food
Distribution Program on Indian Reservations
- Medical
Assistance number does not qualify.-
|
|
|
2. Names of all
Children in Household including
Foster Children
Attach additional page if necessary
Last Name First Name
|
Date
of Birth
Month/Day/Year
|
G
r
a
d
e
|
School
|
P if
foster
child *
|
Any Regular
Income to Child
(for
example SSI)
|
|
If applicable
Active Case Number
For any household member
|
|
|
|
|
___/___/___
|
|
|
*
|
$_____ per_____
|
|
Case Number: _____________
* MFIP
* Food Support (Stamps)
* FDPIR
(Not Medical
Assistance)
|
|
|
|
___/___/___
|
|
|
*
|
$_____ per_____
|
|
|
|
___/___/___
|
|
|
*
|
$_____ per_____
|
|
|
|
___/___/___
|
|
|
*
|
$_____ per_____
|
|
|
|
___/___/___
|
|
|
*
|
$_____ per_____
|
|
|
|
|
|
|
|
|
|
|
|
* The child is the legal
responsibility of a welfare agency or court. If all children applied for are
foster children, skip Sections 3 and 4.
|
4. Names of all Adults in Household (all household members not
listed in Section 2)
Include all
adults living in your household, related or not. Attach additional page if necessary.
First Name Last Name
|
Check
if
NO
Income
P ü
|
Household Incomes: Write in each gross income
and how often it is received: weekly (W), bi-weekly (every other week) (BW), twice per month (TM), monthly (M). Do not write in hourly pay. If income fluctuates, write in the
amount normally received. Attach additional page if necessary.
|
|
Gross Wages and Salaries -
all jobs
- before deductions -
|
Pension, SSI, Retirement,
Social Security
|
Public Assistance, Child Support, Alimony
|
Unemployment, Worker’s Comp,
Strike Benefits
|
Any Other Income, including net
Farm/
Self-Employment
|
|
|
|
|
$_____ per ____
|
$_____ per ____
|
$_____ per ____
|
$_____ per ____
|
$_____ per ____
|
|
|
|
|
$_____ per ____
|
$_____ per ____
|
$_____ per ____
|
$_____ per ____
|
$_____ per ____
|
|
|
|
|
$_____ per ____
|
$_____ per ____
|
$_____ per ____
|
$_____ per ____
|
$_____ per ____
|
|
|
|
|
|
|
|
|
|
5. If your children are approved for school meal
benefits, this information may be shared with MinnesotaCare and General
Assistance Medical Care programs to identify children eligible for Minnesota health
insurance programs. See back page for more information. Leave the boxes blank
to allow sharing of information.
o Do not share information with the MinnesotaCare
health insurance program. o Do not share information with the General
Assistance Medical Care program.
6.
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 and state funds based on the information I give. I understand that if I
purposely give false information, my children may lose meal benefits and I may
be prosecuted.
Signature of Adult Household
Member (required) ______________________________
Print Name: ___________________________ Date: ________
Social Security number – last 4 digits (required if
Section 4 is completed): ___ ___ ___ ___
OR o I don’t have
a Social Security number
Address:
____________________________________ City _______________________ Zip_________ Home Phone: ______________ Work Phone:
____________
Privacy
Act Statement / How Information Is Used
The National School Lunch Act
requires that the household member signing the application must provide the
last four digits of their Social Security Number unless an active Minnesota
Family Investment Program (MFIP), Food Support (SNAP) or Food Distribution
Program on Indian Reservations (FDPIR) assistance number is supplied for your
child, or you are applying for a foster child, or you do not have a Social
Security number. Provision of a Social Security number is not mandatory, but if
a Social Security number is not given or an indication is not made that the
signer does not have such a number, the application cannot be approved.
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.
At public school districts,
each student's eligibility status is also recorded on a statewide computer
system used to report student data to the Minnesota Department of Education as
required by state law. The Minnesota Department of Education uses this
information to: (1) administer state and federal programs; (2) calculate
compensatory revenue for public schools; and, (3) judge the quality of the
state's educational program.
Sharing Information with MinnesotaCare and General
Assistance Medical Care Programs
Children who are eligible for
free and reduced-price school meals may be eligible for Minnesota health
insurance programs. Your child’s eligibility status for school meals (qualified
for free or reduced-price meals) may be shared with the MinnesotaCare and
General Assistance Medical Care programs unless you tell us not to share your
information by checking the boxes in section 5 of the application. You are not
required to share information for this purpose and your decision will not
affect approval for school meal benefits.
Civil Rights Survey (voluntary)
This information is
requested solely for the purpose of determining compliance with federal
civil rights laws, and will not affect your application. By providing this
information, you will assist us in assuring that this program is
administered in a nondiscriminatory manner.
1. Ethnicity (check one):
£ Hispanic or
Latino £ Not Hispanic or Latino
2. Race (check one or more):
£ American
Indian or Alaskan Native £ Native Hawaiian or Other Pacific Islander
£ Asian £ White
£ Black or
African American
|
|
Nondiscrimination
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. 20250-9410 or
call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or
have speech disabilities may contact USDA through the Federal Relay Service at
(800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity
provider and employer.
|
|
Children’s Ethnic and Racial Identities (Optional)
Please provide the
following information, which is used to determine the institution’s
compliance with civil rights laws. If the information is left blank, a
representative of the institution is required to identify the ethnic and racial
categories of participants for civil rights reporting.
- Choose one ethnicity:
* Hispanic/Latino
* Not Hispanic/Latino
2. Choose one or more (regardless of ethnicity):
* Asian * American Indian or Alaskan Native * Black or
African American
* Native Hawaiian or other Pacific Islander * White
|
|
May 2011
[Print on School District Letterhead]
Notice of Approval or Denial
For Free or Reduced-Price
School Meals
School Year 2011-12
Dear Parent or Guardian: Date: _________
Your application for free or
reduced-price meals for your child or children is:
___ Approved effective _____(date)______
for
___ Free Breakfast ___ Free Lunch
___ Reduced-Price Lunch. Your cost is
________ per lunch.
___ Temporarily approved for (free or
reduced-price) meals until (date) .
Your
child or children may have received school meal benefits this year prior to the
effective date shown above if they were approved for meal benefits last school
year.
___ Denied because:
___
Your total household income is over the allowable amount.
___ Your application
was incomplete. Please complete and return the enclosed application. The
following information is missing:
___ Names of all household members.
___ Sources of income for each household
member.
___ Signature of an adult household
member.
___ The last four digits of the Social
Security number of the person signing the application, or an indication that
the person has no Social Security number.
___ Other:
___________________________________________________
You
may reapply for benefits at any time during the school year. You should reapply
to find out whether you are eligible for school meal benefits if you become
unemployed or otherwise have a decrease in household income or have an increase
in the size of your household.
If
you do not agree with this denial, you may discuss it with a school official.
If you wish to review the decision further, you have a right to a fair hearing.
This can be done by calling or writing: [List contact information for hearing official]
Sincerely, [District
Official]
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 school
is prohibited from discrimination 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.
20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are
hearing impaired or have speech disabilities may contact USDA through the
Federal Relay Service at (800) 877-8339; or (800) 845-6136. USDA is an equal
opportunity provider and employer.
