Marsh Valley School District #21 PO Box 180 Arimo, ID 83214

Dear Parent/Guardian:

Children need healthy meals to learn. Marsh Valley School District #21 offers healthy meals every school day. Breakfast is free; lunch costs for elementary $1.55 and secondary $1.80. Your children may qualify for free meals or for reduced price meals. Reduced price is $ .40 for lunch.

1. Do I need to fill out an application for each child? No. Complete the application to apply for free or reduced price meals. 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: Rose Lee Evans, PO Box 180, Arimo, ID , 254-9185.

2. Who can get free meals? Children in households getting Food Stamps or TAFI and most foster children can get free meals regardless of your income. Also, your children can get free price meals if your household income is within the free limits on the Federal Income Guidelines.

3. Can homeless, runaway and migrant children get free meals? Please call Rose Lee Evans, 254-9185, to see if your child(ren) qualify, if you have not been informed that they will get free meals.

4. Who can get reduced price meals? Your children can get low cost meals if your household income is within the reduced price limits on the Federal Income Chart, shown on this application.

5. Should I fill out an application if I got a letter this school year saying my children are approved for free or reduced price meals? Please read the letter you got carefully and follow the instructions. Call the District Office, 254-9185 if you have questions.

6. I get WIC. Can my child(ren) get free meals? Children in households participating in WIC may be eligible for free or reduced price meals. Please fill out an application.

7. Will the information I give be checked? Yes, we may ask you to send written proof.

8. If I don’t qualify now, may I apply later? Yes. You may apply at any time during the school year if your household size goes up, income goes down, or if you start getting Food Stamps, TAFI or other benefits. If you lose your job, your children may be able to get free or reduced price meals.

9. 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: Marvin Hansen, Superintendent, PO Box 180, Arimo, ID 83214, 254-3306.

10. May I apply if someone in my household is not a U.S. citizen? Yes. You or your child(ren) do not have to be a U.S. citizen to qualify for free or reduced price meals.

11. Who should I include as members of my household? You must include all people living in your household, related or not (such as grandparents, other relatives, or friends). You must include yourself and all children who live with you.

12. What if my income is not always the same? List the amount that you normally get. For example, if you normally get $1000 each month, but you missed some work last month and only got $900, put down that you get $1000 per month. If you normally get overtime, include it, but not if you get it only sometimes.

13. We are in the military, do we include our housing allowance as income? If your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. All other allowances must be included in your gross income.

If you have other questions or need help, call 254-9185.

Si necesita ayuda, por favor llame al teléfono: 254-9185.

Si vous voudriez d’aide, contactez nous au numero: 254-9185.

Sincerely,

Rose Lee Evans

April 2009 Free and Reduced Price School Meals Application

Letter to Households

Page 1 of 2

INSTRUCTIONS FOR APPLYING

If your household gets FOOD STAMPS, TAFI, or FDPIR follow these instructions:

Part 1: List child(ren)’s name, school, grade, and a Food Stamp or TAF/FDPIRI case number.

Part 2: Check the appropriate box, if any.

Part 3: Skip this part.

Part 4: Skip this part.

Part 5: Sign the form. A Social Security Number is not necessary.

Part 6: Answer this question if you choose to.

Check the appropriate box and contact [your school, homeless liaison, migrant coordinator].

Fill out application by following instructions for ALL OTHER HOUSEHOLDS.

If you are applying for a FOSTER CHILD, follow these instructions:

Part 1: Use a separate application for each foster child. List the child’s name, school, and grade.

Part 2: Skip this part.

Part 3: Check the box and list the child’s personal use monthly income, if any.

Part 4: Skip this part.

Part 5: Sign the form. A Social Security Number is not necessary.

Part 6: Answer this question if you choose to.

ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:

Part 1: List each child’s name, school, and grade.

Part 2: Check the appropriate box, if any.

Part 3: Skip this part.

Part 4: Follow these instructions to report total household income from last month.

1. List the first and last name of each person living in your household, related or not (such as grandparents, other relatives, or friends). You must include yourself and all children. Attach another sheet of paper if you need to.

2. List Gross income last month and how often it was received not listed in PART 1 unless they have income. Next to each person’s name list each type of income received last month, and how often it was received. If a person does not have income, check the “No Income” box. For example, Earnings from work: List the gross income each person earned from work. This is not the same as take-home pay. Gross income is the amount earned before taxes and other deductions. The amount should be listed on your pay stub, or your boss can tell you. Next to the amount, write how often the person got it (weekly, every other week, twice a month, or monthly). All other income: List the amount each person got last month from welfare, child support, alimony, pensions, retirement, Social Security, and ALL OTHER INCOME SOURCES. In the All Other column, include Worker’s Compensation, unemployment, strike benefits, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), disability benefits, regular contributions from people who do not live in your household, and ANY OTHER INCOME. Report net income for self-owned business, farm, or rental income. Next to the amount, write how often the person got it. If you are in the Military Housing Privatization Initiative do not include this housing allowance.

Part 5: An adult household member must sign the form and list his or her Social Security Number, or mark the box if he or she doesn’t have one.

Part 6: Answer this question if you choose to.

April 2009 Free and Reduced Price School Meals Application

Letter to Household

Page 2 of 2

One Application per Household

FREE AND REDUCED PRICE SCHOOL MEALS FAMILY APPLICATION

Part 1. Children in School (Use a separate application for each foster child)

Names of all children in school (First, Middle Initial, Last)

School Name

Grade

Food Stamp, TAFI/FDPIR case # (if any). Skip to Part 5 if

you list a Food Stamp, TAFI/FDPIR case #

Part 2. If the child you are applying for is homeless, migrant, or a runaway check the appropriate box and call [your school, homeless liaison, migrant coordinator at phone #] Homeless �� Migrant �� Runaway ��

Part 3. Foster Child

If this application is for a child who is the legal responsibility of a welfare agency or court, check this box �� and then list the amount of the child’s personal use monthly income: $__________. Skip to Part 5.

Part 4. Household Members and Gross Income—You must tell us how much and how often. List the names of everyone in your household and income they receive except for children listed above (unless they have income.) If household member listed below has no income, you must check the NO INCOME box.

1. NAME

2. Check if NO Income

3. Gross income and how often income is received must be answered.

Example: $100/monthly $100/twice a month $100/every other week $100/weekly

Earnings from work before deductions

Welfare, child support, alimony received

Pensions, retirement, Social Security

All Other Income

How How

Much? Often?

How How

Much? Often?

How How

Much? Often?

How How

Much? Often?

$______/_______

$______/________

$______/________

$______/_______

$______/_______

$______/________

$______/________

$______/_______

$______/_______

$______/________

$______/________

$______/_______

$______/_______

$______/________

$______/________

$______/_______

$______/_______

$______/________

$______/________

$______/_______

$______/_______

$______/________

$______/________

$______/_______

Part 5. Signature and Social Security Number (Adult must sign)

An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list his or her Social Security Number or mark the “I do not have a Social Security Number” box. (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 based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted.

Sign here: X_______________________________________ Print name:______________________________________________ Date: ______________

Address:_____________________________________________ ______________________________________ Phone Number:________________

Street/Apt. Number or P.O. Box No. City, State, Zip

Social Security Number: __ __ __ - __ __ - __ __ __ __ �� I do not have a Social Security Number

Part 6. Children’s racial and ethnic identities (optional)

Mark one or more racial identities: Mark one ethnic identity:

�� Asian �� American Indian or Alaska Native �� Hispanic or Latino

�� White �� Native Hawaiian or Other Pacific Islander �� Not Hispanic or Latino

�� Black or African American �� Other

DO NOT WRITE IN BOX BELOW - FOR SCHOOL USE ONLY

ANNUAL INCOME CONVERSION: Weekly X 52, Every 2 Weeks X 26, Twice a Month X 24, Monthly X 12

o FOOD STAMP/TAFI/FDPIR HOUSEHOLD

o INCOME HOUSEHOLD: Total household income: $______________________ How often __________________

Household size: _________

DENIED:

o Income Over Allowed Amount

o Incomplete/Missing o Other

TEMPORARY APPROVAL FOR:

oFree Meals, expires ____________________

oReduced-Price Meals, expires ____________

APPROVED FOR:

o Free Meals

o Reduced-Price Meals

o ______________________ Reduced-Price Meals

WITHDRAWAL DATE

VERIFICATION RESULTS:

o No Change o Free to Reduced o Reduced to Free

o Ineligible (Reason)

Signature of Confirming Official __________________________________

Signature of

Determining Official: X

Signature of

Verifying Official: X

Date

Date

Signed:

Date

Signed:

Date 1^st

Notification Sent:

Date 2^nd

Notification Sent:

April 2009 Free and Reduced Price School Meals Application

Application

Page 1 of 2

FEDERAL INCOME CHART For School Year July 1,2009 to June 30, 2010
Household size	Yearly	Monthly	Weekly
1	20,036	1,670	386
2	26,955	2,247	519
3	33,874	2,823	652
4	40,793	3,400	785
5	47,712	3,976	918
6	54,631	4,553	1,051
7	61,550	5,130	1,184
8	68,469	5,706	1,317
Each additional person:	+6,919	+577	+134

Your children may qualify for free or reduced price meals if your household income falls within the limits on this chart.

Privacy Act Statement: This explains how we will use the information you give us.

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 social security number of the adult household member who signs the application. The social security number is not required when you apply on behalf of a foster child or you list a Food Stamp Program, Temporary Assistance for Families in Idaho (TAFI) 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.

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 institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington DC 20250-9410 or call (800) 795-3272 or (202) 720-6382 (voice and TTY). USDA is an equal opportunity provider and employer.

April 2009 Free and Reduced Price School Meals Application

Application

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