APPLY ONLINE:
Prototype Household Application for Free and Reduced Price School Meals
RETURN TO (School/District Name):
Complete one application per household. Please use a pen (not a pencil).
ADDRESS:
STEP 1
List ALL children, infants, and students up to and including grade 12. Attach another sheet of paper if you need space for more names.
List ALL children in the household. Do not forget to list infants, children attending other schools, children not in school, and children not applying for benefits. This includes children not related to you in your household.
Child’s First Name MI Child’s Last Name
Grade
Foster Child
Migrant Runaway Homeless
If you checked
any of these
boxes, please
refer to the
Application
Instruction’s
Step 1: Part C &
Part D.
NO Go to STEP 3.
YES Write case number here and proceed to STEP 4.
t apply Check all tha
STEP 2
Do any household members (including you) participate in: SNAP, TANF, or FDPIR?
CASE NUMBER (NOT EBT NUMBER):
Write only one case number in this space.
STEP 3
List ALL household members and income for each member (before taxes and deductions)
A. All Adult Household Members (Anyone who is living with you and shares income and expenses, even if not related, including you.)
List all Adult Household Members not listed in STEP 1 (including yourself ) even if they do not receive income. For each Household Member listed, if they receive income, report total gross income (before taxes and
deductions) 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.
Pensions, Retirement,
Social Security, SSI,
VA Benets, All Other
P
ublic Assistance,
Child Support,
Alimony
How often received?
How often received? How often received?
Name of Adult Household Members (First and Last)
Weekly
Every
2 Weeks
Monthly2x Month
$
$
$
$
$
Earnings from Work
Last FLast Four Numbers of Sour Numbers of Social Social Securecuritity Number ofy Number of
PPrrimarimaryy WWage Earage Earner or other Aner or other Adult Householddult Household
MMember (Iember (If Af Applicable)pplicable)
Annual
$
$
$
$
$
Total Household Members (Children and Adults)
B. Child Income
Sometimes children in the household earn or receive income.
Include the TOTAL income (before taxes and deductions) received by ALL children listed in STEP 1 here.
$
Weekly
Every
2 Weeks
Monthly2x Month Annual
Weekly
Every
2 Weeks
Monthly2x Month
$
$
$
$
$
How often received?
Child Income
Check if no SCheck if no Socialocial
SSecurecuritity Numbery Number
Weekly
Every
2 Weeks
Monthly2x Month
Please see application’s back
for list of income sources.
STEP 4
APPLY ONLINE:
RETURN TO (School/District Name):
ADDRESS:
Contact information and adult signature.
RETURN COMPLETED FORM TO YOUR CHILD’S SCHOOL:
Insert school address here
“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 ocials may verify
(conrm) the information. I am aware that if I purposely give false information, my children may lose meal benets, and I may be prosecuted under applicable State and Federal laws.”
Print Name of Adult Signing the Form
Signature of Adult
Today’s Date
Mailing Address (if available)
City
Return completed form to your child’s school.
State Zip
Phone (optional)
Email (optional)
Sela Public Charter School
6015 Chillum Pl NE, Washington, DC 20011
6015 Chillum Pl NE, Washington, DC 20011
selapcs.org