Letter to Parents Page 1

Letter to Parents Page 2

Instructions Page 1

Instructions Page 2


2020-2021 Household Application for Free and Reduced Price School Meals

Complete one application per household.
STEP 1 List ALL Household Members who are infants, children, and students up to and including grade 12.

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 MI Child's Last Name Child's School Grade Student?   Foster Child Homeless, Migrant, Runaway
Yes No

Do any Household Members (including you) currently participate in one or more of the following assistance programs: Food Assistance, TAF, or FDPIR?


If NO > Go to STEP 3.    If YES > write a case number here then go to STEP 4 (Do not complete STEP 3).

Case Number:
  Write only one case number in this space.
STEP 3 Report Income for ALL Household Members (Skip this step if you answered 'Yes' to STEP 2)

Are you unsure what income to include here?

On the following page, review the charts titled "Sources of income" for more information.

The "Sources of Income for Children" chart will help you with the Child income section.

The "Sources of Income for Adults" chart will help you with the All Adult Household Members section.

Go to the following page to learn how to report income from Self Employment.

A. Child Income
Sometimes children in the household earn or receive income. Please include the TOTAL income received by all Household Members listed in STEP 1 here. Child Income How Often?
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 gross income (before taxes) for each source in whole dollars (no cents) 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.
Name of Adult Household Members (First and Last) Earnings from Work How Often? Public
Child Support/Alimony
How Often? Pensions/Retirement /All other income How Often?
Total Household Members
(Children and Adults)        
Last Four Digits of Social Security Number (SSN) of Primary Wage Earner or Other Adult Household Member     Check if no SSN
STEP 4 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) Apt # City State Zip Daytime Phone (Optional) Email (Optional)
Printed Name of adult completing the form Signature of Adult completing the form Today's date
INSTRUCTIONS Sources of Income
Sources of Income for Children
Sources of Child Income Example(s)
Earnings from work
  • A child has a regular full or part-time job where they earn a salary or wages
  • Social Security
  •   -Disability Payments   -Survivor’s Benefits
  • 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
  • Income from person outside the household
  • A friend or extended family member regularly gives a child spending money
  • Income from any other source
  • A child receives regular income from a private pension fund, annuity, or trust
Sources of Income for Adults
  • Salary, wages, cash bonuses
  • Net income from self-employment (farm or business

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
  • Unemployment benefits
  • Worker’s compensation
  • Supplemental Security Income (SSI)
  • Cash assistance from State or local government
  • Alimony payments
  • Child support payments
  • Veteran’s benefits
  • Strike Benefits
  • Social Security (including railroad retirement and black lung benefits)
  • Private pensions or disability benefits
  • Regular income from trusts or estates
  • Annuities
  • Investment income
  • Earned interest
  • Rental income
  • Regular cash payments from outside household

Income from Self Employment: Self-employed persons may use income tax records for the preceding calendar year as a base to project the current year’s net income, unless the current monthly income provides a more accurate measure. Report income derived from the business venture less operating costs incurred in the generation of that income. Deductions for personal expenses such as interest on home payments, medical expenses, and other similar non-business deductions are not allowed in reducing gross business income. Additional income from other kinds of employment must be treated as separate and apart from the income generated or lost from your business venture. For example, if you operated a business at a net loss, but held additional employment for which a salary was received, the income for purposes of applying for reduced price or free meals would be the income from the salary only. The loss from the business cannot be deducted from a positive income earned in other employment.


For purposes of this application, it is not possible to report a negative income from any business venture. The least income possible is zero (no income). The necessary information for arriving at allowable income from private business operation may be taken from your most recent U.S. Individual Income Tax Return - Form 1040. Add together the amounts reported on the following lines:

LINE 12 $_______________ Business Income or (Loss)
LINE 13 $_______________ Capital Gain or (Loss)
LINE 14 $_______________ Other Gains or (Losses)
LINE 17 $_______________ Rental real estate, royalties, partnerships, S corporations, trusts, etc.
LINE 18 $_______________ Farm Income or (Loss)
 TOTAL  $_______________ Gross Annual Income Before Any Deductions.

Computed Monthly Income $_______________ Gross Annual Income ÷ 12 = Computed Monthly Income. Report in Step 3.

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 (choose one): Hispanic or Latino Not Hispanic or Latino    
Race (choose one or more): American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

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 Food Assistance (FA) Temporary Assistance for Families (TAF) 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.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.


Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

  1. Mail: U.S. Department of Agriculture
    Office of the Assistant Secretary for Civil Rights
    1400 Independence Avenue, SW
    Washington, D.C. 20250-9410
  2. Fax: (202) 690-7442; or
  3. Email: program.intake@usda.gov

This institution is an equal opportunity provider.

Do not fill out         FOR SCHOOL USE ONLY - Annual Income Conversion: Weekly x 52, Bi-Weekly x 26, Twice a Month x 24, Monthly x 12
Total Household Income $ Household Size: Eligibility: Free OR               Reduced Price OR                Denied
Household's Income Frequency: Choose One: W  BW  2M  M  Multiple=Yearly Notes:
Category Eligibility: (FA, TAF, FDPIR, Foster )
Determining Official's Signature: Approval/Denial Date: Notification Date:
Processor's Initials: Confirming Official's Signature (ONLY for applications to be verified):   Review Date:


Consent of Disclosure

Sharing Information with Other Programs

Dear Parent/Guardian:

You do not have to complete this section of the form to get reduced price or free Child Nutrition Program benefits for your children. If you do not sign the Consent of Disclosure, it will not affect eligibility for or participation in the Child Nutrition Programs.

To save you time and effort, information about your children's eligibility for reduced price or free Child Nutrition Program benefits may be shared with other programs for which your children may qualify. For the program listed below, we must have your permission to share your information.

No, I DO NOT want information about my children's eligibility for Child Nutrition Program benefits shared with this program.

Yes, I DO want school officals to share information about my children's eligibility for Child Nutrition Program benefits with the program I have checked below.

    Enrollment/Book Fees

    ACT Test Fees (High School Only)

If you checked yes to any or all of the boxes above, fill out the form below. Your information will be shared only with the program you checked.

Child's Name:
Child's Name:
Child's Name:
Child's Name:
Child's Name:
Child's Name:



* Required Information

For more information you may call Eileen Sagner

        Phone: 316-542-3512      E-Mail: esagner@usd268.org

This institution is an equal opportunity provider.



If you click "submit" and do not get a Thank You screen the form did not successfully process, please try again or call Information Services at 316-542-3512.