Elementary Free/Reduced Lunch Application - Waukesha School ...

PART 1. ALL HOUSEHOLD MEMBERSFREE AND REDUCED PRICE SCHOOL MEALS FAMILY APPLICATIONNames of all people living in your household(First, Middle Initial, Last)School the child attends, or indicate “NA”if household member is not in schoolGradeCheck if a foster child (legalresponsibility of welfare agency or court)If all children listed below are fosterchildren, skip to Part 5 to sign this form.Check ifNOincomePART 2. BENEFITSIf any member of your household receives FoodShare, FDPIR or W‐2 CashBenefits, provide the name and case number for the person who receivesbenefits and skip to part 5. If no one receives these benefits, go to Part 3.NAME:CASE NUMBER:PART 3. HOMELESS, MIGRANT, RUNAWAY STATUSIf any child you are applying for is homeless, migrant,or a runaway check the appropriate box and call ErinLee, Homeless Liaison, at 262‐970‐3533HOMELESS MIGRANT RUNAWAY PART 4. TOTAL HOUSEHOLD GROSS INCOME (before deductions). List all income on the same line as the person who receives it. Check the box forhow often it is received. Record each income only once. If you provided a case number in Part 2, you do not need to provide income information.1. NAME(List only household members withincome)2. GROSS INCOME AND HOW OFTEN IT WAS RECEIVEDEarningsfrom workbeforedeductions.WeeklyEvery 2 WeeksTwice MonthlyMonthlyWelfare,childsupport,alimonyWeeklyEvery 2 WeeksTwice MonthlyMonthlyPensions,retirement, SocialSecurity, SSI, VAbenefitsWeeklyEvery 2 WeeksTwice MonthlyMonthlyAll Other Income(indicate frequency, suchas “weekly” “monthly”“quarterly” “annually”)(Example) Jane Smith $200 $150 $0 $50 / quarterly$ $ $ $ /$ $ $ $ /$ $ $ $ /$ $ $ $ /$ $ $ $ /$ $ $ $ /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 herSocial Security Number or write “none” if you do not have a Social Security Number. (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 basedon the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, mychildren may lose meal benefits, and I may be prosecuted.Sign here: Print name: Date:Address: City: State: Zip Code:Phone Number:Cell Phone Number:Last four digits of Social Security Number (Write “None” if you do not have a Social Security Number): * * * ‐ * * ‐ __ __ __ __Free and Reduced Price School Meal ApplicationSchool Year 2013‐2014Application Page 2 of 2