389

Jefferson School District

School Site __

2009 — 2010

Martin Luther King Jr. Education Center 101 Lincoln Avenue, Daly City, CA 94015 Tel 650.746-2516 • Fax 650.991-1298

APPLICATION FOR FREE & REDUCED PRICE MEALS

SECTION A: All households complete this section and return application to school EXCEPT those that received a Blue 2009-2010 Direct Certification Letter, unless you do not want to apply. FOOD STAMP (FS), FOR ALL STUDENT / CHILD INFORMATION CALWORKS, KINGAP OR FOSTER CHILD SCHOOL (ONE DAY OLD THROUGH 20 YRS OLD) FDPIR BENEFITS USE ONLY CURRENT

CHILDREN’S LAST NAMES

CHILDREN’S FIRST NAMES

SCHOOL INITIALS Write N/A if not in school

R O O M

#

G WRITE R YES A Or NO D E

If YES, enter case number below for each child

If YES, complete one application per Foster Child. Enter child’s monthly personal-use income

WRITE

YES OR

NO

1.

STUDENT ID

$

2. 3. 4. 5. If you entered a Food Stamp, CalWORKS, KinGAP or FDPIR case number for each child in Section A, or if this application is for a Foster Child and you entered his/her monthly personal-use income, skip Section B and complete Section C SECTION B: HOUSEHOLD MEMBERS(see back for definition) and THEIR MONTHLY INCOME (IF ANY) (1) List all adult household members, whether or not they have income; (2) Indicate amount(s) and source(s) of income for those adult household members with income last month; (3) Enter any income received last month by/for a child from full-time or regular part-time employment, SSI or Adoption Assistance payments; and (4) If amount last month was more/less than usual, enter the usual amount. (5) If no income write “0” (zero). ALL ADULTS FULL NAMES

1. 2. 3. 4. 5.

MONTHLY Gross earnings from work before deductions; include all jobs

Pension, retirement, social security income

Welfare benefits, child support, alimony payments

Any other monthly income

$ $ $ $ $

$ $ $ $ $

$ $ $ $ $

$ $ $ $ $

FOR SCHOOL USE ONLY TOTAL MONTHLY INCOME

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 any other means. Privacy Act Statement: National School Lunch Act (Section 9) requires that, unless your child’s Food Stamp, CalWORKS, KinGAP or FDPIR case number is provided, you must include the social security number of the adult household member signing the application or indicate that the household member signing the application does not have a social security number. Provision of a social security number is not mandatory, but if a social security number is not given or an indication is not made that the signer does not have such a number, the application cannot be approved. The social security number may be used to identify the household member in carrying out efforts to verify the correctness of the information stated on the application. These verification efforts may be carried out through program reviews, audits, and investigations and may include contacting employers to determine income, contacting the State’s Employment Development Department offices, or local welfare offices to determine the amount of benefits received and checking the documentation produced by household members to prove the amount of income received. Reporting incorrect information may result in loss or reduction of the household’s program benefits, or in administrative claims and/or legal actions against household members.

SECTION C: ALL HOUSEHOLDS READ and COMPLETE THIS SECTION I certify 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 the information on the application at any time, and that deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws. Signature of adult household member completing this form:

Telephone Number: ( )

Date:

Printed name of adult household member signing this application:

Social Security Number (write “none” if N/A):

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

2. Mark one ethnic identity:

Total # of adults and children in household:

This institution is an Equal Opportunity Provider and Employer Black or African-American

Asian

Of Hispanic or Latino origin

Native Hawaiian or Pacific Islander

White

Not of Hispanic or Latino origin

FOR SCHOOL USE ONLY — ELIGIBILITY DETERMINATION 8/13/2009 Direct Certified as: H M R _____ EP FREE REDUCED DENIED CATEGORICALLY FREE WITH FOOD STAMP, CALWORKS, KINGAP OR FDPIR BENEFITS ZERO INCOME, TEMPORARY FREE UNTIL (UP TO 45 CALENDAR DAYS FROM DATE OF THIS DETERMINATION): ND

2 REVIEW:

VERIFICATION OFFICIAL:

DATE:

FOLLOW-UP:

HOUSEHOLD SIZE:

HOUSEHOLD INCOME:

DETERMINING OFFICIAL:

DATE:

Jefferson School District

101 LINCOLN AVENUE  DALY CITY  CA  94015 Dear Parent/Guardian: The JEFFERSON SCHOOL DISTRICT serves lunch every school day. Students may buy lunch for $2.75. Students may be eligible for free meals if they reside in households receiving food stamps, KinGAP, FDPIR, or CalWORKS. They also may receive meals free of charge or at a reduced price of $ .40 if their household incomes are within the levels shown on the scale below. To apply for free or reduced price meals, please complete the application on the reverse side and return it to the school as soon as possible. New applications must be submitted each school year, except for those notified by mail of Direct Certification. Instructions for completing the application follow. The application cannot be approved unless it contains complete eligibility information. FOR FOOD STAMP, CALIFORNIA WORK OPPORTUNITY AND RESPONSIBILITY TO KIDS (CALWORKS), KINSHIP GUARDIANSHIP ASSISTANCE PAYMENTS (KINGAP) OR FOOD DISTRIBUTION PROGRAM INDIAN RESERVATIONS (FDPIR) HOUSEHOLDS: If you now receive Food Stamp, CalWORKS, KinGAP, or FDPIR benefits for your child(ren), you should have received a yellow notification of Direct Certification and you DO NOT submit a new application. If you did not receive a notification of eligibility through Direct Certification for your child(ren), list each child’s name, and your Food Stamp, CalWORKS, KinGAP, or FDPIR case number. New students are not directly certified and some continuing students may have been inadvertently missed in the matching process. New applications must be filled out for those students. If a Food Stamp, CalWORKS, KinGAP, or FDPIR case number for the child is listed, or if the application is for a foster child, a social security number is not needed. An adult household member must sign the application. WIC PARTICIPANTS: If you currently receive benefits under the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC Program), your child may be eligible for free or reduced-price meals. You are encouraged to complete an application and return it to the school for processing. FOSTER OR INSTITUTIONALIZED CHILDREN: Use one application per foster or institutionalized child who is the legal responsibility of the welfare agency or the court. Write the name of the child and the specific school he/she attends. If the child receives “personal use income”, list the amount of income. “Personal use income” is (a) money given by the welfare office identified by category for the child’s personal use, such as clothing, school fees and allowances; and (b) all other money the child gets, such as money from family and money from the child’s full-time or regular part-time jobs. A social security number is not needed. If a child is living with relatives or friends and is not a ward of the court or the welfare agency, the application must be completed with all household members and income listed. . In some cases Foster children are eligible for free or reduced-price meals regardless of the household’s income. The foster parent or agency official must sign the application. ALL OTHER INCOME HOUSEHOLDS (wages, salary, pensions, etc.): For each student listed on the application, you must enter: the names of all the children and the schools they attend, the names of other children who do not attend any school, the names of all the adults (21 years and older) and other household members, the amount each person received last month, and the source of income. HOUSEHOLD means a group of related, or non-related, individuals who are living as one economic unit and sharing living expenses. Living expenses include rent, clothes, food, doctor bills, and utility bills. An adult household member must sign the application and enter their social security number. Indicate “none” if the adult does not have a social security number. An application must be completed, with all household members and income listed, for a child who is living with relatives or friends, whether or not the child is a ward of the court. Incomplete applications may be returned. CURRENT INCOME: The amount of income each household member received last month, before taxes or anything else that is taken out, and where it came from, such as earnings, welfare, pensions, and other income. If any amount last month was more or less than usual, write the usual monthly income or project the annual income. To figure monthly income: Annual Income divided by 12; Twice per Month=annual income divided by 24; Every 2 weeks =annual income divided by 26; and Weekly=annual income divided by 52. VERIFICATION: The information on the application may be checked by school officials at any time during the school year. Proof may be required. MEALS FOR THE DISABLED: A child with a disability is entitled to a special meal, at no extra charge, if the disability prevents the child from eating the regular school meal. APPLYING FOR FREE & REDUCED MEALS: You may submit an application at any time during the school year. If you are not eligible now, but your income decreases, or if you are no longer employed or your family size changes, or you become eligible for Food Stamp, CalWORKS, KinGAP, or FDPIR benefits you may complete an application at that time. NONDISCRIMINATION: In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Bldg., 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice & TDD). USDA is an equal opportunity provider and employer. Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s Target Center at (202) 720-2600 (voice & TDD). FAIR HEARING: If you do not agree with the decision on your application or the result of verification, you may wish to discuss it with the Food Service Department. You also have the right to a fair hearing. This can be done by calling or writing the following school official: JEFF DAVIES, JEFFERSON SCHOOL DISTRICT, 101 Lincoln Avenue, Daly City, CA 94015 - Phone (650) 746-2411. CONFIDENTIALITY: The information you give on the application will not be given to anyone who is not part of the Jefferson Elementary School District food program. The information will be used only to determine if your children are eligible for free or reduced price meals. If you have any questions, please contact FOOD SERVICES at (650) 746-2516. You will be notified whether your application is approved or denied by our office. Sincerely yours,

Enrique Navas Assistant Superintendent, Business Services INCOME ELIGIBILITY GUIDELINES: JULY 1, 2009 THROUGH JUNE 30, 2010 HOUSEHOLD SIZE

1* 2 3 4 5 6 7 8

YEAR

MONTHLY

TWICE PER MONTH

EVERY TWO WEEKS

WEEKLY

$ 20,036 $ 26,955 $ 33,874 $ 40,793 $ 47,712 $ 54,631 $ 61,550 $ 68,469

$ 1,670 $ 2,247 $ 2,823 $ 3,400 $ 3,976 $ 4,553 $ 5,130 $ 5,706

$ 835 $ 1,124 $ 1,412 $ 1,700 $ 1,988 $ 2,277 $ 2,565 $ 2,853

$ 771 $ 1,037 $ 1,303 $ 1,569 $ 1,836 $ 2,102 $ 2,368 $ 2,634

$ 386 $ 519 $ 652 $ 785 $ 918 $ 1,051 $ 1,184 $ 1,317

For each additional household member add: + $ 6,919 $ 577 $ 289 $ 267 $ 134 * A household of one means a foster child, a child in out-of-home care, or a pupil who is his/her sole support.