Apply online:
2020-2021 Oregon Household 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)
Homeless,
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.
Student?
Foster
Migrant,
Child’s First Name MI Child’s Last Name
Grade
Yes No
Child
Runaway
Check all that apply
STEP 2
Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?
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
ReportIncomeforALLHouseholdMembers (Skipthisstepifyouanswered‘Yes’toSTEP2)Report Income forALLHouseholdMembers (Skip this step if youanswered‘Yes’ toSTEP2)
How often?
X X
X X X
Are you unsure what
income to include here?
Flip the page and 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.
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.
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.
Child income
$
Weekly Bi-Weekly 2x Month Monthly
Name of Adult Household Members (First and Last)
Earnings from Work
How often?
Public Assistance/
Child Support/Alimony
How often?
Pensions/Retirement/
All Other Income
How often?
Weekly Bi-Weekly 2x Month Monthly
Weekly Bi-Weekly 2x Month Monthly
Weekly Bi-Weekly 2x Month Monthly
$
$
$
$ $ $
$ $ $
$ $ $
$ $ $
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.
MAIL COMPLETED FORM TO YOUR SCHOOL AT:
“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 and Email (optional)
Printed name of adult signing the form Signature of adult Today’s date