Lemoore Union Elementary School District
APPLICATION FOR FREE AND REDUCED-PRICE MEALS
OR FREE MILK FOR SCHOOL YEAR 2016/2017
COMPLETE AND RETURN THIS APPLICATION TO THE SCHOOL.
(ONE APPLICATION PER FAMILY.)
You can also apply online at EZMEALAPP.COM (Fast/Secure)
Please apply at the high school for your high school student. / DO NOT WRITE HERE : FOR SCHOOL USE ONLY – ELIGIBILITY DETERMINATION
HOUSEHOLD SIZE: / HOUSEHOLD INCOME: $
FREE: / REDUCED: / DENIED:
FREE: CALFRESH(SNAP)// CalWORKs// Kin-GAP/ FDPIR , FOSTER CARE / Direct Certified as: H M R
EP
DETERMINING OFFICIAL: / DATE: / 2nd Review:
SECTION A. SHOW ALL STUDENTS/CHILDREN IN YOUR FAMILY THAT YOU SUPPORT IN THIS SECTION / VERIFICATION OFFICIAL: / DATE: / Follow-up:

ONLY ONE APPLICATION PER FAMILY IS NEEDED AND NOT PER

STUDENT.

(YOUR STUDENT / CHILD INFORMATION):

(if you need additional space please add on the back side)
ONLY LIST MINOR CHILDREN HERE
The high school will determine eligibility for your high school student-Apply at the high school. / CIRCLE PROGRAM:
CalFresh (SNAP, Food Stamps),
CALWORKS (Cash Aid),
KIN-GAP, or
FDPIR BENEFITS (Food Distribution Program on Indian Reservation) / Complete only if the child is receiving FOSTER CARE SERVICES and you answered Yes. (If you adopted this child
Do NOT complete this section and proceed to Section B listing your family’s income)
/ FOR SCHOOL
USE ONLY
(DO NOT WRITE HERE)
STUDENT/CHILD
(last name) / STUDENT/CHILD
(first name) / school
name and student id#
(if not in school write none)
example: Meadow
#11111 /
are you receiving these programs?
write yes or
no below
/ if yes, write
case number below (not your card#). if not kings county also write county name /
write yes or
no
/ if yes, write child’s
monthly
personal-use income received (exclude what you receive from the foster agency) /

student id

1.
2.
3.
4.
5.
* If you entered a CalFresh, CalWORKs, Kin-GAP, Foster Care, or FDPIR case number for all children in Section A, or if this application is only for a foster child and you entered his/her monthly personal-use income, SKIP Section B and complete Section C. You may now include Foster Care children on the same application of your other children but you will also need to complete Section B and Section C.
SECTION B. HOUSEHOLD MEMBERS IN YOUR FAMILY (include yourself) THAT YOU SUPPORT AND THEIR INCOME (IF ANY). If no Income show zeros.
(1)List all ADULT household members in YOUR family economic unit that you support, regardless of income; (2)Indicate amount(s) and source(s) of income for those adult household members with income last month or amount they expect to receive (if no income show zeros); (3)Also write any income you received last month or expect to receive for a child from full-time or regular part-time employment, SSI, Social Security, or Adoption Assistance payments; and (4)If amount last month was more/less than usual, enter the usual amount. Please indicate how often the gross paycheck or other amounts listed below are paid (example: week, month, twice per month, or every two weeks). If you work seasonal JOBS OR YOUR INCOME AMOUNT CHANGES EACH PAYPERIOD, write your annual income and THE WORD yEAR NEXT TO IT. (circle the type of income you receive).
(COMPLETE ALL BOXES)
. Please answer each box by writing an amount or a zero (if no income). If you enter “0” or leave any fields blank you are certifying (promising) that there is no income to report from the sources shown in this section.
full name (ADULT) that you
support (include yourself)
(Do not list children from Section A, If you have income to report that you receive for a child please write it in the line of the adult that receives it)
Example: First/Last Name / gross paycheck amount
from all jobs before
deductions (write what you receive gross each pay day, not your net-pay, don’t add all your checks for a month) (Show each adult separately)
self-employment income: write net income
military income: include bah and food/clothing allowances
Example: $250.00 week / circle program
pension,
retirement,
social security, disability, unemployment
(include amounts you receive for children under your name)
*If you receive unemployment or disability payments please write the amount you receive every 2 weeks
* include benefits for
a child on the line of the adult who receives the check
Example: $ 110.00 two weeks / circle program
welfare cash
benefits (calworks), child support, alimony
payments
(this is only for payments that are received from these programs )
Example: $35.00 month / list other
income here and write source
(examples: interest, dividend, rental income, other income)
ALSO INCLUDE THE TOTAL EARNED INCOME FOR A CHILD
Example: $75.00 week interest / for school
use only:
(do not write here)
1.
2.
3.
4.
5.
California Education Code Section 49557(a):Applications for free and reduced-price meals may be submitted at any time during a school day. Children participating in the National School Lunch Program will not be overtly identified by the use of special tokens, special tickets, special serving lines, separate entrances, separate dining areas, or by any other means.
INFORMATION STATEMENT—Richard B. Russell National School Lunch Act requires the information on this Application. You do not have to provide 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 SSN of the adult household member who signs the Application. The last four digits of the SSN is not required when you apply on the behalf of a foster child or when you list a CalFresh, CalWORKs, KinGAP, or 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 SSN. Your family size, household income, and the last four digits of your SSN will remain confidential and will not be shared. 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.
SECTION C. ALL HOUSEHOLDS READ AND COMPLETE THIS SECTION
Certification: “I certify (promise) that all of the above information is true and correct and that all income is reported. I understand that this information is given for the receipt of federal funds, that school officials may verify (check) the information on the application. 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.”.
signature of ONE adult household member completing this form / telephone number and email address / date
printed name of the adult household member signing this application / social security number (last 4 digits) or if you don’t have one place a mark on the next box I do not have a SSN
address
city / state / zip code
SECTION D. CHILDREN’S RACIAL AND ETHNIC IDENTITIES (Optional)
1.Mark one or more racial identities:American Indian or Alaska Native Asian Black or African-America Native Hawaiian or Other Pacific Islander White
2.Mark one ethnic identity: Of Hispanic or Latino Origin Not of Hispanic or Latino Origin
This institution is an equal opportunity provider.