1. No category

August 21, 2015
For Immediate Release
Contact:
Vista School – (435) 673-4110
National School Lunch
Free and Reduced-price Policy Announced
Vista School today announced their policy for free and reduced price meals for children unable
to pay the full price of meals served under the National School Lunch Program. If the LEA
participates in the program, they will have a copy of the policy, which may be reviewed by any
interested party.
Copies of this media release are available upon request to any interested person by visiting our
webpage www.vistautah.com or calling our main office phone line at (435) 673-4110.
The attached household size and income criteria will be used for determining eligibility
this year. Children from families whose income is at or below the levels shown are eligible for
free or reduced price meals.
When known to the LEA, households will be notified of the children’s eligibility for free
meals if they are members of households receiving assistance from Food Stamps (SNAP), Food
Distribution Program on Indian Reservations (FDPIR), or the Family Employment
Program (FEP). LEAs will approve these children or households for free meals through the
direct certification process and no application is required for free meal benefits. All children in
these households are eligible for free meal benefits and if any child(ren) was not listed on the
eligibility notice, the household should contact the school to have benefits extended to that
child(ren). When a child(ren) or household receives benefits under Assistance Programs or
other source programs are not notified by the school of their free meal benefits, the parent or
guardian should contact their school.
Foster children who are legal wards of the court or state are eligible for free meal
benefits. If a household has foster children and wishes to apply for meal benefits for such
children, the household should complete the application. Foster children may be included as
household members, if the foster family is not eligible for free or reduced price meal benefits, it
does not prevent a foster child from receiving benefits.
When known to the LEA, households will be notified of any child’s eligibility for free
meals if the individual child is Other Source Categorically Eligible because the child is
categorized, as defined by law as: homeless, migrant, runaway, enrolled in an eligible Head
Start, or enrolled in an eligible pre-kindergarten class. If any children were not listed on the
notice of eligibility, the household should contact the LEA or school about their eligibility
through an Other Source Categorically Eligible Program or should submit an income application.
Application forms or instructions to complete an online application form for those not
directly certified have been sent home including a letter to parents or guardians. To apply for
free or reduced price meals, households should fill out the application and return it
to their school or district office. The information provided on the application will be used for
the purpose of determining eligibility and may be verified at any time during the school year by
school or other program officials. Children’s names, eligibility status and other information
provided on the paper application or obtained through direct certification may be disclosed to
certain other Federal, State, or local agencies as authorized by the National School Lunch Act
(NSLA).
For the school officials to determine eligibility, the household must provide complete
information listed on the application: names of all household members; last four digits of the
Social Security Number of the household’s primary wage earner or another adult household
member on the application, or a statement that the person does not have a social Security
Number; the income received by each household member with income frequency and income
source noted; and the signature of an adult household member certifying that the information
provided is correct. Households will be notified by the LEA of their eligibility and children will
be provided free meal benefits unless the household notifies the school that it chooses to
decline benefits. Applications may be submitted at any time during the year. If a household
member becomes unemployed or if the household situation changes, the family should contact
the school. Such changes may make the children of the household eligible for free or reduced
priced meals.
For up to 30 operating days into a new school year, eligibility from the previous year will
continue within the same LEA. When the carry-over period ends, unless the household is
notified that their children are directly certified or the household submits an application that is
approved, the children must pay full price for school meals and the school will not send a
reminder or a notice of expired eligibility. Under the provisions of the free and reduced price
policy, a designated approving official at the LEA will review applications and determine
eligibility. If a parent or guardian is dissatisfied with the ruling of the official, he/she may wish
to discuss the decision on an informal basis with the approving official. If the parent/guardian
wishes to make a formal appeal, he/she may make a request either orally or in writing to the
LEA hearing official by contacting the local school food service supervisor for more information.
The policy contains an outline of the hearing procedure.
The information provided by the household is confidential and will be used only for
purposes of determining eligibility and verifying data, unless a wavier releasing the use of the
information for other specific programs is signed by the parent or guardian. Directly certified
households will receive a wavier release form with the notification letter. The household name
and address will be given to the Children’s Health Insurance Program (CHIP) unless “No” is
checked on the back of the application.
Supplemental Nutrition Program for Women, Infants & Children (WIC) may be eligible
for free or reduced price meals. Individuals should complete an application for free and
reduced price meals and return it to the school where the child is enrolled. The family will be
notified of the child’s eligibility.
“The U.S. Department of Agriculture prohibits discrimination against its customers,
employees, and applicants for employment on the bases of race, color, national origin, age,
disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital
status, familial or parental status, sexual orientation, or all or part of an individual’s income is
derived from any public assistance program, or protected genetic information in employment
or in any program or activity conducted or funded by the Department. (Not all prohibited bases
will apply to all programs and/or employment activities.)
“If you wish to file a Civil Rights program complaint of discrimination, complete the
USDA Program Discrimination Complaint Form, found online at
http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 6329992 to request the form. You may also write a letter containing all of the information
requested in the form. Send your completed complaint form or letter to us by mail at
U.S. Department of Agriculture
Director, Office of Adjudication
1400 Independence Avenue, S.W.
Washington, D.C. 20250-9410
or by fax (202) 690-7442 or email at [email protected].
“Individuals who are deaf, hard of hearing 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.”
The Income Eligibility Guidelines for free and reduced price school meals are shown
below. These guidelines are used by schools, institutions, and facilities participating in the
National School Lunch Program, School Breakfast Program, Special Milk Program for Children,
Child and Adult Care Food Program and Summer Food Service Program and are effective from
July 1 through June 30 every year. The Income Eligibility Guidelines are also located online at
http://www.fns.usda.gov/cnd/Governance/notices/iegs/IEGs.htm.
Income Eligibility Guidelines
Effective from July 1, 2015 to June 30 2016
Household Size
1
2
3
4
5
6
7
8
For each
additional
family member
add
Reduced price meals -- 185%
BiAnnual Monthly TwiceMonthly weekly
21,775 1,815
908
838
29,471 2,456
1,228
1,134
37,167 3,098
1,549
1,430
44,863 3,739
1,870
1,726
52,559 4,380
2,190
2,022
60,255 5,022
2,511
2,318
67,951 5,663
2,832
2,614
75,647 6,304
3,152
2,910
7,696
642
321
296
Free meals -- 130%
BiWeekly Annual Monthly TwiceMonthly weekly
419
15,301 1,276
638
589
567
20,709 1,726
863
797
715
26,117 2,177
1,089
1,005
863
31,525 2,628
1,314
1,213
1,011
36,933 3,078
1,539
1,421
1,159
42,341 3,529
1,765
1,629
1,307
47,749 3,980
1,990
1,837
1,455
53,157 4,430
2,215
2,045
148
5,408 451
226
208
Weekly
295
399
503
607
711
815
919
1,023
104
FREQUENTLY ASKED QUESTIONS ABOUT FREE AND
REDUCED PRICE SCHOOL MEALS
Dear Parent/Guardian:
Children need healthy meals to learn. Vista School offers healthy meals every school day. Lunch costs
$2.50. Your children may qualify for free meals or for reduced price meals. Reduced price is $.40 for
lunch. This packet includes an application for free or reduced price meal benefits, and a set of detailed
instructions. Below are some common questions and answers to help you with the application process.
1. WHO CAN GET FREE OR REDUCED PRICE MEALS?
 All children in households receiving benefits from State SNAP, the Food Distribution
Program on Indian Reservations (FDPIR) or State TANF, are eligible for free meals.
 Foster children that are under the legal responsibility of a foster care agency or court are
eligible for free meals.
 Children participating in their school’s Head Start program are eligible for free meals.
 Children who meet the definition of homeless, runaway, or migrant are eligible for free meals.
 Children may receive free or reduced price meals if your household’s income is within the limits
on the Federal Income Eligibility Guidelines. 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 2015-16
Household size
1
2
3
4
5
6
7
8
Each additional person:
Yearly
Monthly
Weekly
21,775
29,471
37,167
44,863
52,559
60,255
67,951
75,647
1,815
2,456
3,098
3,739
4,380
5,022
5,663
6,304
419
567
715
863
1,011
1,159
1,307
1,455
7,696
642
148
2. HOW DO I KNOW IF MY CHILDREN QUALIFY AS HOMELESS, MIGRANT, OR RUNAWAY? Do the
members of your household lack a permanent address? Are you staying together in a shelter, hotel, or
other temporary housing arrangement? Does your family relocate on a seasonal basis? Are any children
living with you who have chosen to leave their prior family or household? If you believe children in your
household meet these descriptions and haven’t been told your children will get free meals, please call or
e-mail homeless liaison or migrant coordinator.
3. DO I NEED TO FILL OUT AN APPLICATION FOR EACH CHILD? No. 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: Vista
School c/o Kayla Clark, 585 East Center Street, Ivins, UT 84738.
4. SHOULD I FILL OUT AN APPLICATION IF I RECEIVED A LETTER THIS SCHOOL YEAR SAYING MY
CHILDREN ARE ALREADY APPROVED FOR FREE MEALS? No, but please read the letter you got
carefully and follow the instructions. If any children in your household were missing from your eligibility
notification, contact Kayla Clark, 435-673-4110 ext. 303, [email protected] immediately.
5. CAN I APPLY ONLINE? Yes! You are encouraged to complete an online application instead of a paper
application if you are able. The online application has the same requirements and will ask you for the
same information as the paper application. Visit www.vistautah.com or through your Aspire SIS
account to begin or TO learn more about the online application process. Kayla Clark, 435-673-4110
ext. 303, [email protected] if you have any questions about the online application.
6. MY CHILD’S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT A NEW 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.
7. 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 send in an application.
8. WILL THE INFORMATION I GIVE BE CHECKED? Yes. We may also ask you to send written proof of
the household income you report.
9. 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.
10. 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 Kayla Clark, 435-673-4110
ext. 303, [email protected].
11. MAY I APPLY IF SOMEONE IN MY HOUSEHOLD IS NOT A U.S. CITIZEN? Yes. You, your children, or
other household members do not have to be U.S. citizens to apply for free or reduced price meals.
12. 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.
13. WHAT IF SOME HOUSEHOLD MEMBERS HAVE NO INCOME TO REPORT? Household members may
not receive some types of income we ask you to report on the application, or may not receive income at
all. Whenever this happens, please write a 0 in the field. However, if any income fields are left empty or
blank, those will also be counted as zeroes. Please be careful when leaving income fields blank, as we
will assume you meant to do so.
14. WE ARE IN THE MILITARY. DO WE REPORT OUR INCOME DIFFERENTLY? Your basic pay and cash
bonuses must be reported as income. If you get any cash value allowances for off-base housing, food, or
clothing, or receive Family Subsistence Supplemental Allowance payments, it must also be included as
income. However, if your housing is part of the Military Housing Privatization Initiative, do not include
your housing allowance as income. Any additional combat pay resulting from deployment is also
excluded from income.
15. WHAT IF THERE ISN’T ENOUGH SPACE ON THE APPLICATION FOR MY FAMILY? List any additional
household members on a separate piece of paper, and attach it to your application. Kayla Clark, 435673-4110 ext. 303, [email protected] to receive a second application.
16. MY FAMILY NEEDS MORE HELP. ARE THERE OTHER PROGRAMS WE MIGHT APPLY FOR? To find
out how to apply for [State SNAP] or other assistance benefits, contact your local assistance office or
call 2-1-1.
If you have other questions or need help, call (435) 673-4110.
Sincerely,
Kayla Clark, Data Services
HOW TO APPLY FOR FREE AND REDUCED
PRICE SCHOOL MEALS
Please use these instructions to help you fill out the application for free or reduced price school meals.
You only need to submit one application per household. The application must be filled out completely to
certify your children for free or reduced price school meals.
Please follow these instructions in order! Each step of the instructions is the same as the steps on your
application. If at any time you are not sure what to do next, please contact Kayla Clark, 435-6734110 ext. 303, [email protected] .
PLEASE USE A PEN (NOT A PENCIL) WHEN FILLING OUT THE APPLICATION AND DO YOUR BEST
TO PRINT CLEARLY.
STEP 1:
LIST ALL HOUSEHOLD MEMBERS WHO ARE INFANTS, CHILDREN, AND STUDENTS
UP TO AND INCLUDING GRADE 12
Tell us how many infants, children, and school students live in your household. They do NOT have to be
related to you to be a part of your household.
Who should I list here?
When filling out this section, please include all members in your household who are:

Children age 18 or under and are supported with the household’s income;

In your care under a foster arrangement, or qualify as homeless, migrant, or runaway
youth;

Students attending other schools regardless of age.
A) List each child’s name. For each child, print their first name, middle initial and last name. Use one
line of the application for each child. When printing names, write one letter in each box. Stop if you run
out of space. If there are more children present than lines on the application, attach a second piece of
paper with all required information for the additional children.
B) Is the child a student at Vista School? Mark ‘Yes’ or ‘No’ under the column titled “Student” to tell
us which children attend Vista School.
C) Do you have any foster children? If any children listed are foster children, mark the “Foster Child”
box next to the child’s name. Foster children who live with you may count as members of your
household and should be listed on your application. If you are only applying for foster children, after
completing STEP 1, skip to STEP 4 of the application and these instructions.
D) Are any children homeless, migrant, or runaway? If you believe any child listed in this section
may meet this description, please mark the “Homeless, Migrant, Runaway” box next to the child’s name
and complete all steps of the application.
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How to Apply for School Meal Benefits| Application Instructions
SY 2015-16
STEP 2:
DO ANY HOUSEHOLD MEMBERS (INCLUDING YOU) CURRENTLY PARTICIPATE IN
ONE OR MORE OF THE FOLLOWING ASSISTANCE PROGRAMS: SNAP, TANF, OR FDPIR?
If anyone in your household participates in the assistance programs listed
below, your children are eligible for free school meals:



The Supplemental Nutrition Assistance Program (SNAP)
Temporary Assistance for Needy Families (TANF)
The Food Distribution Program on Indian Reservations (FDPIR)
A) IF NO ONE IN YOUR HOUSEHOLD PARTICIPATES IN ANY OF THE ABOVE LISTED PROGRAMS:

Circle ‘NO’ and skip to STEP 3 on these instructions and STEP 3 on your application.

Leave STEP 2 blank.
B) IF ANYONE IN YOUR HOUSEHOLD PARTICIPATES IN ANY OF THE ABOVE LISTED PROGRAMS:

Circle ‘YES’ and provide a case number for SNAP, TANF, or FDPIR. You only need to write
one case number. If you participate in one of these programs and do not know your case number,
contact: [State/local agency contacts here]. You must provide a case number on your
application if you circled “YES”.

Skip to STEP 4.
STEP 3:
REPORT INCOME FOR ALL HOUSEHOLD MEMBERS
A) Report all income earned by children. Refer to the chart titled “Sources of Income for Children” in
these instructions and report the combined gross income for ALL children listed in Step 1 in your
household in the box marked “Total Child Income.” Only count foster children’s income if you are
applying for them together with the rest of your household. It is optional for the household to list foster
children living with them as part of the household.
What is Child Income?
Child income is money received from outside your household that is paid
directly to your children. Many households do not have any child income. Use
the chart below to determine if your household has child income to report.
Sources of Income for Children
Sources of Child Income
Earnings from work




2

Social Security
o Disability Payments
o Survivor’s Benefits

Income from persons outside the
household
Income from any other source



Example(s)
A child has a job where they earn a salary
or wages.
A child is blind or disabled and receives
Social Security benefits.
A parent is disabled, retired, or deceased,
and their child receives social security
benefits.
A friend or extended family member
regularly gives a child spending money.
A child receives income from a private
pension fund, annuity, or trust.
How to Apply for School Meal Benefits| Application Instructions
SY 2015-16
FOR EACH ADULT HOUSEHOLD MEMBER:
Who should I list here?
When filling out this section, please include all members in your household who are:

Living with you and share income and expenses, even if not related and even if they do not
receive income of their own.
Do not include people who:

Live with you but are not supported by your household’s income and do not contribute
income to your household.

Children and students already listed in Step 1
How do I fill in the income amount and source?
FOR EACH TYPE OF INCOME:

Use the charts in this section to determine if your household has income to report.

Report all amounts in gross income ONLY. Report all income in whole dollars. Do not
include cents.
o Gross income is the total income received before taxes or deductions.
o Many people think of income as the amount they “take home” and not the total,
“gross” amount. Make sure that the income you report on this application has
NOT been reduced to pay for taxes, insurance premiums, or any other amounts
taken from your pay.

Write a “0” in any fields where there is no income to report. Any income fields left empty or
blank will be counted as zeroes. If you write ‘0’ or leave any fields blank, you are certifying
(promising) that there is no income to report. If local officials have known or available
information that your household income was reported incorrectly, your application will be
verified for cause.

Mark how often each type of income is received using the check boxes to the right of each
field.
B) List Adult Household member’s name. Print the name of each household member in the boxes
marked “Names of Adult Household Members (First and Last).” Do not list any household members you
listed in STEP 1. If a child listed in STEP 1 has income, follow the instructions in STEP 3, part A.
C) Report earnings from work. Refer to the chart titled “Sources of Income for Adults” in these
instructions and report all income from work in the “Earnings from Work” field on the application. This is
usually the money received from working at jobs. If you are a self-employed business or farm owner, you
will report your net income.
What if I am self-employed?
If you are self-employed, report income from that work as a net amount. This is
calculated by subtracting the total operating expenses of your business from its
gross receipts or revenue.
D) Report income from Public Assistance/Child Support/Alimony. Refer to the chart titled “Sources
of Income for Adults” in these instructions and report all income that applies in the “Public
Assistance/Child Support/Alimony” field on the application. Do not report the value of any cash value
public assistance benefits NOT listed on the chart. If income is received from child support or alimony,
only court-ordered payments should be reported here. Informal but regular payments should be reported
as “other” income in the next part.
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How to Apply for School Meal Benefits| Application Instructions
SY 2015-16
E) Report income from Pensions/Retirement/All other income. Refer to the chart titled “Sources of
Income for Adults” in these instructions and report all income that applies in the
“Pensions/Retirement/All Other Income” field on the application.
F) Report total household size. Enter the total number of household members in the field “Total
Household Members (Children and Adults).” This number MUST be equal to the number of household
members listed in STEP 1 and STEP 3. If there are any members of your household that you have not
listed on the application, go back and add them. It is very important to list all household members, as the
size of your household determines your income cutoff for free and reduced price meals.
G) Provide the last four digits of your Social Security Number. The household’s primary wage earner
or another adult household member must enter the last four digits of their Social Security Number in the
space provided. You are eligible to apply for benefits even if you do not have a Social Security
Number. If no adult household members have a Social Security Number, leave this space blank and mark
the box to the right labeled “Check if no SS#.”
Sources of Income for Adults
Earnings from Work

Salary, wages, cash
bonuses
Net income from selfemployment (farm or
business)
Strike benefits


If you are in the U.S. Military:

Basic pay and cash
bonuses (do NOT include
combat pay, FSSA or
privatized housing
allowances)

Allowances for off-base
housing, food, and
clothing
Public Assistance/Alimony/
Child Support

Unemployment benefits

Worker’s compensation

Supplemental Security
Income (SSI)

Cash assistance from
State or local
government

Alimony payments

Child support payments

Veteran’s benefits
Pensions/Retirement/All
Other Income

Social Security
(including railroad
retirement and black
lung benefits)

Private Pensions or
disability

Income from trusts or
estates

Annuities

Investment income

Earned interest

Rental income

Regular cash payments
from outside household
STEP 4: CONTACT INFORMATION AND ADULT SIGNATURE
All applications must be signed by an adult member of the household. By signing the application,
that household member is promising that all information has been truthfully and completely reported.
Before completing this section, please also make sure you have read the privacy and civil rights
statements on the back of the application.
A) Provide your contact information. Write your current address in the fields provided if this
information is available. If you have no permanent address, this does not make your children
ineligible for free or reduced price school meals. Sharing a phone number, email address, or both is
optional, but helps us reach you quickly if we need to contact you.
B) Sign and print your name. Print your name in the box “Printed name of adult completing the form.”
And sign your name in the box “Signature of adult completing the form.”
C) Write Today’s Date. In the space provided, write today’s date in the box.
D) Share children’s Racial and Ethnic Identities (optional). On the back of the application, we ask
you to share information about your children’s race and ethnicity. This field is optional and does not
affect your children’s eligibility for free or reduced price school meals.
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How to Apply for School Meal Benefits| Application Instructions
SY 2015-16
2015-2016 Utah Application for Free and Reduced Price School Meals
Complete one application per household. Please use a pen (not a pencil).
STEP 1
List ALL Household Members who are infants, children, and students up to and including grade 12 (if more spaces are required for additional names, attach another sheet of paper)
Definition of Household member: “Anyone who is living with you and shares income and expenses, even if not related.”
Children in Foster care and children who meet the definition of Homeless, Migrant or Runaway are eligible for free meals. Read How to Apply for Free and Reduced Price School Meals for more information.
Child’s First Name
STEP 2
Child’s Last Name
Grade Name of School
Homeless,
Foster Migrant,
Child Runaway
Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR? Circle one: Yes / No
If you answered NO > Complete STEP 3
STEP 3
MI
Student?
Yes No
If you answered YES > Write a case number here, then go to STEP 4 (Do not complete STEP 3)
Case Number:
Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2)
Please read How to Apply for Free and Reduced Price School Meals for more information. The Sources of Income for Children section will help you with the Child Income question. The Sources of Income for Adults section will help you with the All Adult Household Members section.
How Often?
A. Child Income
Child income
Sometimes children in the household earn income. Please include the TOTAL income earned by all Household Members listed in STEP 1 here.
Weekly Bi-Weekly 2x Month Monthly
$
B. All Adult Household Members (including yourself)
List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. 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’ or leave any fields blank, you are certifying (promising) that there is no income to report.
Name of Adult Household Member (First and Last)
Total Household Members
(Children and Adults)
STEP 4
Earnings From Work
How often?
Weekly Bi-Weekly 2x Month Monthly
Pensions/Retirement/
How Often?
All Other Income
Weekly Bi-Weekly 2x Month Monthly
How Often?
Public Assistance/
Child Support/Alimony Weekly Bi-Weekly 2x Month Monthly
$
$
$
$
$
$
$
$
$
$
$
$
Last Four Digits of Social Security Number of Primary
Wage Earner or Other Adult Household Member
X X X
X X
Check if no Social Security Number
Contact information and adult signature
“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 I may be prosecuted under applicable State and Federal laws.”
Street Address (if available)
Printed name of adult completing the form
Apt #
City
Signature of adult completing the form
State
Zip
Daytime Phone and Email (optional)
Today’s date
OPTIONAL
Children’s Racial and Ethnic Identities
We are required to ask for 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 price meals.
Ethnicity (check one):
Hispanic or Latino
Not Hispanic or Latino
Race (check one or more):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
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  Converted Annual
Categorical Eligibility: ____
Household size: ________
Eligibility: Free___ Reduced___ Denied___ Error Prone 
Determining Official’s Signature: ________________________________________________ Date: _______________
Date Withdrawn :_______ Reason for denial or withdrawal: ______________________________________________
Confirming Official’s Signature: _________________________________________________ Date: _______________
Verifying Official’s Signature: __________________________________________________ Date: _______________
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.
The U.S Department of Agriculture prohibits discrimination against its customers,
employees, and applicants for employment on the bases of race, color, national origin,
age, disability, sex, gender identity, religion, reprisal, and where applicable, political
beliefs, marital status, familial or parental status, sexual orientation, or all or part of an
individual’s income is derived from any public assistance program, or protected genetic
information in employment or in any program or activity conducted or funded by the
Department. (Not all prohibited bases will apply to all programs and/or employment
activities.)
If you wish to file a Civil Rights program complaint of discrimination, complete
the
USDA
Program
Discrimination
Complaint
Form,
found
online
at
http://www.ascr.usda.gov/complaint filing cust.html, or at any USDA office, or call (866)
632-9992 to request the form. You may also write a letter containing all of the information
requested in the form. Send your completed complaint form or letter to us by mail at U.S.
Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue,
S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at
[email protected].
Individuals who are deaf, hard of hearing 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.
COMO SOLICITAR COMIDA ESCOLAR
GRATUITA Y DE PRECIO REDUCIDO
Favor utilice estas instrucciones para llenar la solicitud para recibir comida escolar gratuita o de precio
reducido. Solamente necesita completar una solicitud por hogar, aún si sus hijos asisten a más de una
escuela en [Distrito Escolar]. Debe llenar completamente la solicitud para solicitar comida gratuita o de
precio reducido para sus hijos.
Favor siga estas instrucciones en el orden indicado. Cada paso de las instrucciones corresponde a los
pasos en la solicitud. Si en algún momento usted no está seguro cómo responder, favor de contactar
Kayla Clark, (435) 673-4110 ext. 303, [email protected].
FAVOR USE UN BOLÍGRAFO (NO LÁPIZ) AL LLENAR LA SOLICITUD Y ESCRIBA EN LETRA CLARA Y
DE MOLDE.
PASO 1:
HAGA UNA LISTA DE TODOS LOS BEBÉS, NIÑOS Y ESTUDIATES HASTA EL GRADO
12 MIEMBROS DE SU HOGAR.
Diga cuántos bebés, niños y estudiantes viven en su hogar. Ellos no tienen que ser parientes para ser
parte de su hogar.
¿A quiénes debo incluir en esta lista?
Al llenar esta sección, favor incluya a todos los miembros de su hogar que son:

Menores de 18 o menos años sustentados por el ingresos del hogar;

Niños/as en su cuidado temporal que califican como jóvenes sin hogar,
migrantes, o fugitivos;

Estudiantes que asisten a otras escuelas no importa la edad.
A) Haga una lista con los nombres de cada niño. Para cada niño, imprima su primer nombre, inicial
de su segundo nombre, y apellido. Ponga sólo un nombre por línea. Al escribir los nombres, ponga una
sola letra en cada casilla. No continúe si no hay más casillas. Si no le alcanzan las líneas del formulario,
agregue una hoja con toda la información requerida para los niños adicionales.
B) ¿Es el niño o la niña estudiante en [nombre de la escuela/distrito escolar aquí]? Marque “Sí” o
“No” bajo la columna titulada “Estudiante” para indicar los niños que asisten a Vista School.
C) ¿Tiene algún niño adoptivo temporal (foster)? Si algún niño(a) está con usted como adoptivo
temporal, marque la casilla titulada “Foster Child” al lado del nombre del niño(a). Los niños adoptivos
temporales que viven con usted se considerarán como miembros de su hogar y deben ser listados
en su solicitud. Si usted está solicitando solamente para los niños adoptivos temporales, después de
completar PASO 1, vaya al PASO 4 de la solicitud y estas instrucciones.
D) ¿Hay niños sin hogar, migrantes o fugitivos? Si usted cree que algún niño listado en esta sección
puede caber en estas descripciones, favor marque la casilla al lado del nombre del niño(a) titulada “Sin
Hogar, migrante, Fugitivo” y complete todos los pasos de la solicitud.
PASO 2: ¿PARTICIPA
ALGÚN MIEMBRO DE SU HOGAR, INCLUYÉNDOSE A USTED, EN UNO O
MÁS DE LOS SIGUIENTES PROGRAMAS DE ASISTENCIA: SNAP, TANF O FDPIR?
Si alguien en su hogar participa en los programas de asistencia indicados abajo, sus
niños son elegibles para recibir comida gratuita escolar:



El Programa Suplementario de Asistencia Nutricional (SNAP) o [inserte aquí SNAP Estatal]
Asistencia Temporal para Familias Necesitadas (TANF) o [inserte aquí TANF Estatal]
El Programa de Distribución de Alimentos en Reservaciones Indígenas (FDPIR)
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A) SI NADIE EN SU HOGAR PARTICIPA EN ALGUNO DE LOS PROGRAMAS MENCIONADOS ARRIBA:

Marque con un círculo “NO” y vaya al PASO 3 en estas instrucciones y PASO 3 en su
solicitud.

Deje en blanco PASO 2.
B) SI ALGUIEN EN SU HOGAR PARTICIPA EN ALGUNO DE LOS PROGRAMAS MENCIONADOS
ARRIBA:

Marque con un círculo “SÍ” e indique un número de caso para el SNAP, TANF, o FDPIR.
Usted necesita escribir sólo un número de caso. Si usted participa en uno de estos programas y
desconoce su número de caso, contacte [información de contacto para el Estado /agencia
local]. Usted debe proveer un número de caso en su solicitud si usted marcó con un círculo
“SÍ”.

Vaya al PASO 4.
PASO 3: DECLARE EL INGRESO
DE TODOS LOS MIEMBROS DEL HOGAR
A) Reporte todos los ingresos de los niños. Vea tabla titulada “Fuentes de Ingreso Para Niños” en
estas instrucciones y reporte el ingreso total bruto para TODOS los niños listados en Paso 1 en la casilla
señalada “Ingreso Total del Niño.” Solamente incluya el ingreso de los niños adoptivos temporales si
usted está solicitando para ellos junto con el resto de los miembros de su hogar. Es opcional incluir en la
lista los niños adoptivos temporales que viven en el hogar.
¿Qué es el Ingreso del Niño? Ingreso del niño se refiere al dinero recibido de
una fuente fuera del hogar y pagado directamente a sus niños. Muchos
hogares no reciben ingreso para sus niños. Use la tabla abajo para determinar
si su hogar tiene ingreso del niño para reportar.
FUENTES DE INGRESOS PARA NIÑOS


Fuentes de Ingreso del Niño
Ganancia del trabajo

Seguro Social
o Pagos por Incapacidad
o Beneficios Para Sobrevivientes


Ingresos de otras personas que no
pertenecen al hogar


Ingreso de cualquier otra fuente

2

Ejemplos
Un niño tiene un trabajo que le paga un
salario.
Un niño es ciego o con incapacidad que
recibe beneficios de seguro social.
Uno de los padres tiene una incapacidad,
es pensionado o difunto, y su hijo recibe
beneficios de seguro social.
Amigos o familiares que generalmente
mandan dinero al niño.
Un niño recibe un ingreso de fondos de
jubilación privados, anualidades o
fideicomiso.
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PARA CADA ADULTO DEL HOGAR:
¿A quién debo poner en esta lista?
Al llenar esta sección, favor incluya a todos los miembros de su hogar que:

Viven con usted y comparte ingresos y gastos, aun si ellos no son parientes y aun si no
reciben sus propios ingresos.
No incluya a personas que:

Viven con usted pero no se están manteniendo con el ingreso de su hogar y no contribuyen
ingresos a su hogar.

Niños y estudiantes que ya están en la lista del Paso1.
¿Cómo lleno el formulario con la cantidad y fuente del ingreso?
PARA CADA CLASE DE INGRESO:

Use las tablas en esta sección para determinar si su hogar tiene ingresos que reportar.

Reporte SOLAMENTE el ingreso bruto total. Reporte todo ingreso en dólares redondeados
sin incluir centavos.
o El ingreso bruto es el ingreso total recibido antes de restar impuestos o
deducciones.
o Mucha gente considera ingreso como la cantidad que le queda y no el total que le
pagan. Asegúrese que el ingreso reportado en esta solicitud es la cantidad antes
de pagar impuestos, prima de seguro, o cualquier otra cantidad sacada de su
sueldo.

Escriba “0” (cero) en las casillas donde no hay ingresos que reportar. Si deja una casilla
para ingreso en blanco o vacía, se va a considerar como cero y usted está certificando que
no hay ingreso para reportar. Si los oficiales locales tienen disponible información de que
el ingreso de su hogar fue reportado incorrectamente, su solicitud será verificada.

Marque la frecuencia con que recibe ingresos usando las casillas al derecho de cada línea.
B) Haga una lista de los adultos miembros del hogar. Escriba en letra de molde el nombre de cada
miembro del hogar en las casillas marcadas “Nombres de Miembros Adultos del Hogar (Primer Nombre y
Apellido).” No incluya a los miembros del hogar usted puso en el PASO 1. Si un(a) niño(a) listado(a) en
PASO 1 tiene ingreso, siga las instrucciones en PASO 3, Parte A.
C) Reporte ingresos de su trabajo. Consulte la tabla titulada “Fuentes de Ingresos” en estas
instrucciones y reporte ingresos en el espacio correspondiente en la solicitud. Éstos son ingresos
recibidos de su trabajo. Si usted es trabajador independiente o agricultor, usted reportará su ingreso
neto.
¿Y si soy trabajador independiente?
Si usted es trabajador independiente, reporte el ingreso de su trabajo como neto. Éste
se calcula restando los costos de su negocio de las entradas totales o ingreso bruto.
D) Reporte Ingresos de Asistencia Pública/Manutención de Menores/Pensión Matrimonial. Consulte la
tabla titulada “Fuentes de Ingresos Para Adultos” en estas instrucciones y reporte todo ingreso en la
casilla “Asistencia Pública/Manutención de Menores/Pensión Matrimonial” en la solicitud. No reporte el
valor de beneficios en efectivo de cualquier asistencia pública que no está incluida en la tabla. Si hay
ingreso de manutención de menores o pensión matrimonial, solamente pagos ordenados por una corte
deben ser reportados aquí. Pagos informales pero regulares deberían ser reportados como “otro” ingreso
en la próxima sección.
E) Reporte ingresos de Pensión/Jubilación/Otros Ingresos. Consulte la tabla titulada “Fuentes de
Ingresos de Adultos” en estas instrucciones y reporte todo ingreso relacionado en el espacio de la
solicitud titulado “Pensiones/Jubilación/Otros Ingresos.”
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F) Reporte el Número Total de Personas en el Hogar. Ponga el número total de los miembros del hogar
en el espacio “Número Total de los Miembros del Hogar (Niños y Adultos).” Este número DEBE ser igual
a la suma de los miembros del hogar listados en el PASO 1 y el PASO 3. Si hay miembros del hogar que
usted no ha puesto en las listas de la solicitud, vuelva a la solicitud y agréguelos. Es muy importante
poner en las listas a todos los miembros de su hogar porque el número de personas en su hogar
determina el límite o tope del ingreso usado para determinar si puede recibir comida gratuita o de precio
reducido.
G) Escriba los últimos cuatro números del Seguro Social. El/la asalariado/(a) principal u otro miembro
adulto del hogar debe escribir los últimos cuatro números del Seguro Social en el espacio indicado. Usted
es elegible para solicitar beneficios aun si no tiene un número del Seguro Social. Si ningún miembro
adulto del hogar tiene número del Seguro Social, deje en blanco este espacio y ponga una “X” en la casilla
a la derecha titulada “Marque si no hay SS#.”
FUENTES DE INGRESOS PARA ADULTOS
Ingresos del Trabajo



Sueldo, pagos, bonos en
efectivo
Ingreso neto de trabajo
independiente (finca o
negocio propio)
Pagos por huelgas
Si está en las Fuerzas Armadas
de los EE.UU:

Sueldo básico y bonos en
efectivo (No incluya pago
de combate, FSSA o
ayudas privadas de
vivienda)

Ayudas para vivienda
fuera de la base militar,
comida y ropa
Asistencia
Pública/Manutención de
Menores/Pensión Matrimonial

Beneficios de Desempleo

Compensación laboral

Ingreso Complementario
del Seguro Social (SSI)

Asistencia en efectivo del
gobierno estatal o local

Pensión matrimonial

Manutención de menores

Beneficios para los
veteranos de las Fuerzas
Armadas de los EE.UU.
Pensión/Jubilación/Otros
Ingresos








Seguro Social
(incluyendo jubilación
de ferrocarriles y
enfermedad del pulmón
de minero)
Pensiones privadas o por
discapacidad
Ingresos de herencia o
fideicomisos
Anualidades
Ingreso de inversiones
Intereses
Ingresos de alquiler
Pagos regulares en
efectivo de fuentes afuera
del hogar
PASO 4: INFORMACIÓN DE CONTACTO Y FIRMA DE ADULTO
Toda solicitud debe ser firmada por un miembro adulto del hogar. Al firmar la solicitud, ese miembro
del hogar certifica que toda la información ha sido reportada de una manera completa y verdadera. Antes
de completar esta sección, asegúrese también de leer las declaraciones de derechos civiles y de
privacidad al reverso de la solicitud.
A) Provea su información de contacto. Si tiene dirección permanente, escriba su dirección actual en
los espacios correspondientes. Si no tiene una dirección permanente, esto no quiere decir que sus
hijos no son elegibles para recibir comida escolar gratuita o de precio reducido. Poner un número
de teléfono, correo electrónico es opcional, pero nos ayuda a contactarle rápidamente si necesitamos
hacerlo.
B) Firme y escriba su nombre en letra de molde. Escriba su nombre en letra de molde en la casilla
“Nombre en letra de molde del adulto que llena el formulario.” Y firme en la casilla “Firma del adulto que
completa este formulario.”
C) Escriba la Fecha de Hoy. Escriba la fecha de hoy en la casilla indicada.
D) Indique las Identidades Raciales y Étnicas de los Niños (opcional). Al reverso de la solicitud,
pedimos que usted dé información sobre la raza y etnicidad de sus niños. Esta información es opcional
y no afecta la elegibilidad de sus hijos para recibir comida gratuita escolar o de precio reducido.
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