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For faster service, apply ONLINE at https://mealapps.jefcoed.com/lfserver/FRAPPLICATION
Jefferson County Board of Education
Child Nutrition Programs
2100 18th Street South
Birmingham, AL 35209
205-379-2285
1
2503350996
FAMILY APPLICATION FOR FREE AND REDUCED-PRICE SCHOOL MEALS
2015-2016
PLEASE USE PEN (not a pencil)
POR FAVOR USE PLUMA (no un lápiz).
PRINT NEATLY. (ESCRIBE CLARAMENTE CON LETRA DE MOLDE).
List ALL Household Members who are infants, children, and students up to and including grade 12 in Section 1. For additional space use the back.
"X" if foster child
Please indicate if the child listed is a student by marking the "Y" or "N".
( legal responsibility
Child's Lunch ID
(Número de Comida)
(Optional/Opcional)
First Name
(Nombre Del
Estudiante)
Last Name
Date of Birth
(Fecha de
Nacimiento)
MI
(Apellido)
Grade
(Grado)
School Name
(Escuela)
(Optional/Opcional)
(Optional/
Opcional)
(Optional/Opcional)
"X" if Student is
Homeless, Migrant or
of welfare agency
Runaway
Student
(Marque "X" si el
or court )
"X" si niño bajo estudiante es sin hogar,
(Estudiante) cuidado suplente) migrante, o fugitivo/a)
1)
Y
N
2)
Y
N
3)
Y
N
4)
Y
N
5)
Y
N
6)
Y
N
If the child you are applying for is homeless, migrant, runaway - check the appropriate box and call your school, homeless liaison, migrant coordinator at 205-379-2153
2
Do you or any member of the household currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR? Circle Yes or No
Usted o cualquier miembro de la familia actualmente participan en uno o más de los siguientes programas de asistencia: SNAP, TANF o FDPIR? Círculo sí o No
If you answered No > Complete ALL Sections.
If you answered Yes > Write the full case number here (write only one case number ) then continue to Section 3B
Case Number (Número de Caso)
and write down all remaining household members, Skip income portions (3A and 3C) and continue to Section 4.
Si usted contestó sí > escribir el número de caso completo aquí (escritura número de caso único) y luego continuar
a la sección 3B y anote todos los miembros de hogares restantes y luego Total. Omitir y continuar a la sección 4.
NOT EBT CARD NUMBER
Si usted contestó NO > Complete todas las secciones.
Report Income for all Household Members (Skip this step if you answered "Yes" to STEP 2)
Child Income: sometimes children in the household earn income. Please include the TOTAL income earned by all children listed in Section 1.
3
Definition of a Household Member:
who is living with you and shares income and
3b 3B "Anyone
expenses, even if not related"
3C
W E T
For each Household Member listed, if they do receive income, report total income for each source in whole dollars only. If they do not receive income
from any source, write '0'. If you enter '0' or leave any fields blank, you are certifying (promising) that there is no income to report.
Earnings from Work
Public Assistance,
Pensions, Retirement,
before deductions
Child Support,
All Other Income
Alimony
(Ingresos del
(Asistencia social,
(Pensiones, jubilación,
trabajo antes de
pensión para hijos,
seguro social,
las deducciones)
pensión alimenticia)
beneficios de VA)
We
ekly
/ Se
ma
Ev e
na l
ry 2
We
2X
eks
Mo
/2
nth
S em
ly /
Mo
a na
Do
nth
s
sV
ly /
ece
Me
sa
nsu
lM
al
es
ekly
/ Se
ma
Ev e
na l
ry 2
We
2X
eks
Mo
/2
nth
S em
ly /
Mo
a na
Do
nth
s
sV
ly /
ece
Me
sa
nsu
lM
al
es
We
1)
$
W E T
M
$
W E T
M
$
W E T
M
2)
$
W E T
M
$
W E T
M
$
W E T
M
3)
$
W E T
M
$
W E T
M
$
W E T
M
4)
$
W E T
M
$
W E T
M
$
W E T
M
$
W E T
M
$
W E T
M
$
W E T
M
5)
Total Household members (Children and Adults)
Total los miembros de la familia
(niños y adultos) y en la caja
M
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.
We
Name (Nombre)
List All Adult Household Members first and last names (including
yourself) even if they do not receive income.
Lista todos los miembros adultos del hogar primero y apellidos
(incluido usted mismo) incluso si no reciben ingresos.
How often
$
(W) = Weekly/Semanal; (E) = Every 2 Weeks/2 Semanas; (T) = 2 X Monthly/Dos Veces al Mes; (M) = Monthly/Mensual
ekly
/ Se
ma
Ev e
na l
ry 2
We
2X
eks
Mo
/2
nth
S em
ly /
Mo
a na
Do
nth
s
sV
ly /
ece
Me
sa
nsu
lM
al
es
3A
REQUIRED IF PART 3C IS COMPLETED: Last Four Digits of the Primary Wage Earner or Other Adult Household Member's Social Security Number (SSN)
ES NECESARIO SI PARTE 3C SE HA COMPLETADO: Los últimos cuatro dígitos de la primaria asalariado o número de Seguridad Social de otro adulto miembro del hogar
I do not have a Social Security Number
No tengo un número de Seguro Social
XXX - XX -
4An adult household member must sign the application. If you completed Part 5, you must also include the last four digits of any adult household member's SSN or mark the "I do not have a SSN "box. Un
Adult Signature and Contact Information ( Adult Household Member Must Sign )
miembro adulto del hogar debe firmar la solitcitud."I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that
school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits, and may be prosecuted under applicable State and federal laws."
Si ha llenado la Parte 5, el adulto que firma la solicitud debe también anotar su número de seguro social o marcar la parte que dice "No tengo un número de seguro social."(Certifico que la información dada en esta
solicitud es verdadera y que todos los ingresos han sido declarados. Entiendo que la escuela recibirá fondos federales basados en la información que ha dado. Entiendo que las autoridades escolares pueden verificar dicha información. Entiendo que si proveo
información errónea intencionalmente, mis hijos puenden perder los beneficios de alimentos y se me puede hacer proceso legal. Entiendo el estado de elegibilidad de mi hijo puede ser compartida según lo seguido por la ley.)
X
Printed First Name (Nombre de pila)
Signature (Firma)
Address - if available (Dirección postal - Si está disponible)
Apt #
/
Date (Fecha en que se firmo)
City (Ciudad)
State (Estado)
Preferred Notification Letter - (Optional)
(Carta de Notificación Preferida - Opcional)
Printed Last Name (Appellido)
/
-
-
Daytime Phone - Optional (teléfono de día - Opcional)
Zip Code (Código postal)
English (Inglés)
Spanish (Español)
E-mail Address - Optional (Correo Electronico - Opcional)
Children's Racial and Ethnic Identities
5We areOptional:
required to ask for this information about your children's race and ethnicity. This information is important and helps to make sure we are fully serving our community.
Responding to this section is optional and does not affect your children's eligibility for free or reduced priced school meals.
White
Black/African American
Asian
Native Hawaiian/Pacific Islander
American Indian/Alaska Native
Hispanic/Latino
DO NOT FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY
Total Income:
Categorical Eligibility:
Determining Official's Signature:
Verifying Official's Signature
Per:
Eligibility:
Week,
Free
Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12
Every 2 Weeks,
Twice a Month,
Month,
Year
Reduced
Denied
Date Withdrawn:
Confirming Official's Signature
Date
Date
Non-Hispanic/Latino
Household Size
Reason for denial or withdrawal:
Date