Individual Determination Formschool Year 2015-16

Individual Determination FormSchool Year 2015-16

(Residential Clients under the age of 21 only)

Date of Determination: ______School Year ______
Name of Resident:______
Date of Birth:______
/ Age:______
Date Admitted: ______
/ Date of Exit: ______
This person receives an income of $______per month for personal use.
This money is received from:
Social Security
Cabinet of Health and Family Services
Parent or Guardian
Earnings
Other - Explain ______
Under current Federal Regulations, this individual is eligible for:
Free Meals
Reduced Price Meals
Full Price Meals
I certify that to the best of my knowledge and belief, the above information is true and correct.
Signature: ______Title: ______

The U.S. Department of Agriculture (USDA) 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 if 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 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 .

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 (in Spanish).

FOR OFFICE USE ONLY

Re-Verification of Information for the New School Year (July 1st)

School Year ______Income was re-verified? Yes No

Was there a change in eligibility? Yes No

If yes, describe: ______

Signature: ______Title: ______

Date: ______(Rev. 5/2014)

Pg. 1 of 2

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 (in Spanish).

Attention Parent or Guardian July 2015

Pg. 2 of 2

All dorm students must complete this form, there will be no charge for KSB dorm students breakfast or lunch.

Instructions to Complete

Document the date that the form is completed by staff and the current school year (SY = July 1 to June 30).

Identify the name of the resident, date of birth, their current age and the date they were enrolled in the facility.

When the child withdraws or exits the facility, document the date of exit.

Identify the amount of personal income the child receives. If the child receives zero income, then indicate $0.00 as the amount.

When a child receives income, indicate the source of the income.

Compare the income received to the current school year income eligibility guidelines to determine the child’s eligibility status and indicate the status on the form.

Staff member who completed the form must check the box to certify the information and sign the form and indicate their title.

For children who are in residence in multiple school years, complete the re-verification of benefits at the bottom of the page.

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 (in Spanish).