Letter to Household – 5/2019

LETTER TO HOUSEHOLD Lawrence Public Schools

Dear Parent/Guardian:

Children need healthy meals to learn. Lawrence Public Schools offers healthy meals every school day. Your children may qualify for free meals or for reduced price meals.

Meal Charges Elementary Middle or Jr. High High School

Full Price

Reduced Price

Full Price

Reduced Price

Full Price

Reduced Price

Lunch 2.75 .40 2.95 .40 3.00 .40 Breakfast 1.75 .30 1.85 .30 1.90 .30

An application for free or reduced price meal benefits and a set of detailed instructions is included with this letter or available online at www.usd497.org. Contact Nutrition and Wellness Office Staff, 110 McDonald Dr. Lawrence, KS 66044 (785)832-5000 with questions or to request an application be sent. Below are some common questions and answers to help you with the application process.

1. WHO CAN GET FREE OR REDUCED PRICE MEALS?• All children in households receiving benefits from Food Assistance (FA), the Food Distribution

Program on Indian Reservations (FDPIR) or Temporary Assistance for Families (TAF) areeligible for free meals.

• Foster children that are under the legal responsibility of a foster care agency or court are eligiblefor free meals.

• Children participating in their school’s Head Start program are eligible for free meals.• Children who meet the definition of homeless, runaway, or migrant are eligible for free meals.• Children may receive free or reduced price meals if your household’s income is within the limits

on the Federal Income Eligibility Guidelines. Your children may qualify for free or reduced pricemeals if your household income falls at or below the limits on this chart.

2. HOW DO I KNOW IF MY CHILDREN QUALIFY AS HOMELESS, MIGRANT, OR RUNAWAY? Do themembers of your household lack a permanent address? Are you staying together in a shelter, hotel, orother temporary housing arrangement? Does your family relocate on a seasonal basis? Are any childrenliving with you who have chosen to leave their prior family or household? If you believe children in yourhousehold meet these descriptions and haven’t been told your children will get free meals, please call ore-mail Lawrence Public Schools, Ellen Willets (785)832-5000.

3. DO I NEED TO FILL OUT AN APPLICATION FOR EACH CHILD? No. Use one Free and Reduced PriceSchool Meals Application for all students in your household. We cannot approve an application that is notcomplete, so be sure to fill out all required information. Return the completed application to: Nutritionand Wellness Office Staff, 110 McDonald Dr, Lawrence, KS 66044 (785) 832-5000.

4. SHOULD I FILL OUT AN APPLICATION IF I RECEIVED A LETTER THIS SCHOOL YEAR SAYING MYCHILDREN ARE ALREADY APPROVED FOR FREE MEALS? No, but please read the letter you gotcarefully and follow the instructions. If any children in your household were missing from youreligibility notification, contact Nutrition and Wellness Office Staff, 110 McDonald Dr. Lawrence, KS66044 (785)832-5000 immediately.

FEDERAL ELIGIBILITY INCOME CHART For School Year 2019-2020 Household size Yearly Monthly Weekly

1 23,107 1,926 445 2 31,284 2,607 602 3 39,461 3,289 759 4 47,638 3,970 917 5 55,815 4,652 1,074 6 63,992 5,333 1,231 7 72,169 6,015 1,388 8 80,346 6,696 1,546

Each additional person: 8,177 682 158

Letter to Household – 5/2019

5. CAN I APPLY ONLINE? Not Available ,

6. MY CHILD’S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT A NEW ONE? Yes. Your child’s application is only good for that school year and for the first few days of this school year, through September 25,2019. You must send in a new application unless the school told you that your child is eligible for the new school year. If you do not send in a new application that is approved by the school or you have not been notified that your child is eligible for free meals, your child will be charged the full price for meals.

7. I GET WIC. CAN MY CHILDREN GET FREE MEALS? Children in households participating in WIC may be eligible for free or reduced price meals. Please send in an application.

8. WILL THE INFORMATION I GIVE BE CHECKED? Yes. We may also ask you to send written proof of the household income you report.

9. IF I DON’T QUALIFY NOW, MAY I APPLY LATER? Yes, you may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free and reduced price meals if the household income drops below the income limit.

10. WHAT IF I DISAGREE WITH THE SCHOOL’S DECISION ABOUT MY APPLICATION? You should talk to school officials. You also may ask for a hearing by calling or writing to: Paula Murrish, Executive Director, 110 McDonald Dr. Lawrence, KS 66044 (785)832-5000.

11. MAY I APPLY IF SOMEONE IN MY HOUSEHOLD IS NOT A U.S. CITIZEN? Yes. You, your children, or other household members do not have to be U.S. citizens to apply for free or reduced price meals.

12. WHAT IF MY INCOME IS NOT ALWAYS THE SAME? List the amount that you normally receive. For example, if you normally make $1000 each month, but you missed some work last month and only made $900, put down that you made $1000 per month. If you normally get overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income.

13. WHAT IF SOME HOUSEHOLD MEMBERS HAVE NO INCOME TO REPORT? Household members may not receive some types of income we ask you to report on the application, or may not receive income at all. Whenever this happens, please write a 0 in the field. However, if any income fields are left empty or blank, those will also be counted as zeroes. Please be careful when leaving income fields blank, as we will assume you meant to do so.

14. WE ARE IN THE MILITARY. DO WE REPORT OUR INCOME DIFFERENTLY? Your basic pay and cash bonuses must be reported as income. If you get any cash value allowances for off-base housing, food, or clothing, it must also be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. Any additional combat pay resulting from deployment is also excluded from income.

15. WHAT IF THERE ISN’T ENOUGH SPACE ON THE APPLICATION FOR MY FAMILY? List any additional household members on a separate piece of paper, and attach it to your application. Contact Nutrition and Wellness Office Staff, 110 McDonald Dr. Lawrence, KS 66044 (785)832-5000 to receive a second application.

16. MY FAMILY NEEDS MORE HELP. ARE THERE OTHER PROGRAMS WE MIGHT APPLY FOR? To find out how to apply for Food Assistance (FA) or other assistance benefits, contact your local assistance office or call 1-888-369-4777.

If you have other questions or need help, call (785)832-5000.

Sincerely,

Paula Murrish Executive Director Nutrition and Wellness

This institution is an equal opportunity provider.

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plic

atio

n P

acke

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r Fr

ee a

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Re

du

ced

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ce S

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e 1

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PLI

CA

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EDU

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ICE

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ly f

or

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e a

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rice

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oo

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als.

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r tr

ansl

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o t

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ww

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oo

l Nu

trit

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dm

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ion

, Fo

reig

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angu

age

Tra

nsl

atio

n.

P

leas

e u

se t

he

se in

stru

ctio

ns

to h

elp

yo

u f

ill o

ut

the

app

licat

ion

fo

r fr

ee o

r re

du

ced

pri

ce s

cho

ol m

eals

. Yo

u o

nly

nee

d t

o s

ub

mit

on

e ap

plic

atio

n p

er h

ou

seh

old

, ev

en if

yo

ur

child

ren

att

end

mo

re t

han

on

e sc

ho

ol i

n L

awre

nce

Pu

blic

Sch

oo

l. Th

e ap

plic

atio

n m

ust

be

fill

ed o

ut

com

ple

tely

to

cer

tify

yo

ur

child

ren

fo

r fr

ee o

r re

du

ced

pri

ce s

cho

ol m

eals

. P

leas

e fo

llow

th

ese

inst

ruct

ion

s in

ord

er!

Each

ste

p o

f th

e in

stru

ctio

ns

is t

he

sam

e as

th

e s

tep

s o

n y

ou

r ap

plic

atio

n. I

f at

an

y ti

me

you

are

no

t su

re w

hat

to

do

nex

t, p

leas

e co

nta

ct N

utr

itio

n a

nd

Wel

lnes

s, 1

10

McD

on

ald

Dr.

Law

ren

ce, K

S 6

60

44

, 83

2-5

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PLE

ASE

USE

A P

EN (

NO

T A

PEN

CIL

) W

HEN

FIL

LIN

G O

UT

THE

AP

PLI

CA

TIO

N A

ND

DO

YO

UR

BES

T TO

PR

INT

CLE

AR

LY.

STEP

2: D

O A

NY

HO

USE

HO

LD M

EMB

ERS

CU

RR

ENTL

Y P

AR

TIC

IPA

TE IN

FO

OD

ASS

ISTA

NC

E, T

AF,

OR

FD

PIR

? If

an

yon

e in

yo

ur

ho

use

ho

ld (

incl

ud

ing

you

) cu

rre

ntl

y p

arti

cip

ate

s in

on

e o

r m

ore

of

the

ass

ista

nce

pro

gram

s lis

ted

be

low

, yo

ur

child

ren

are

elig

ible

fo

r fr

ee

sch

oo

l me

als:

Foo

d A

ssis

tan

ce (

FA).

•

T

emp

ora

ry A

ssis

tan

ce f

or

Fam

ilie

s (T

AF)

.

•

T

he

Foo

d D

istr

ibu

tio

n P

rogr

am o

n In

dia

n R

eser

vati

on

s (F

DP

IR).

A)

If n

o o

ne

in y

ou

r h

ou

seh

old

par

tici

pat

es

in a

ny

of

the

ab

ove

list

ed

pro

gram

s:

Leav

e ST

EP 2

bla

nk

and

go

to

STE

P 3

.

B)

If a

nyo

ne

in y

ou

r h

ou

seh

old

par

tici

pat

es

in a

ny

of

the

ab

ove

list

ed

pro

gram

s:

Wri

te a

cas

e n

um

ber

fo

r FA

, TA

F, o

r FD

PIR

. Yo

u o

nly

nee

d t

o p

rovi

de

on

e ca

se n

um

ber

. If

you

par

tici

pat

e in

on

e o

f th

ese

pro

gram

s an

d d

o n

ot

kno

w y

ou

r ca

se n

um

ber

, co

nta

ct K

ansa

s D

epar

tmen

t fo

r C

hild

ren

an

d F

amili

es.

Go

to

STE

P 4

.

STEP

3: R

EPO

RT

INC

OM

E FO

R A

LL H

OU

SEH

OLD

MEM

BER

S H

ow

do

I re

po

rt m

y in

com

e?

Use

th

e ch

arts

tit

led

“So

urc

es

of

Inco

me

fo

r A

du

lts”

an

d “

Sou

rce

s o

f In

com

e f

or

Ch

ildre

n”,

pri

nte

d o

n t

he

bac

k si

de

of

the

app

licat

ion

fo

rm t

o d

ete

rmin

e if

yo

ur

ho

use

ho

ld

has

inco

me

to r

epo

rt.

Rep

ort

all

amo

un

ts in

GR

OSS

INC

OM

E O

NLY

. Rep

ort

all

inco

me

in w

ho

le d

olla

rs. D

o n

ot

incl

ud

e ce

nts

. o

G

ross

inco

me

is t

he

tota

l in

com

e re

ceiv

ed b

efo

re t

axe

s.

o

Man

y p

eop

le t

hin

k o

f in

com

e as

th

e am

ou

nt

they

“ta

ke h

om

e” a

nd

no

t th

e to

tal,

“gro

ss”

amo

un

t. M

ake

sure

th

at t

he

inco

me

you

rep

ort

on

th

is a

pp

licat

ion

has

NO

T b

een

re

du

ced

to

pay

fo

r ta

xes,

insu

ran

ce p

rem

ium

s, o

r an

y o

ther

am

ou

nts

tak

en f

rom

yo

ur

pay

.

Wri

te a

“0

” in

an

y fi

eld

s w

her

e th

ere

is n

o in

com

e to

rep

ort

. An

y in

com

e fi

eld

s le

ft e

mp

ty o

r b

lan

k w

ill a

lso

be

cou

nte

d a

s a

zer

o. I

f yo

u w

rite

‘0’ o

r le

ave

any

fiel

ds

bla

nk,

yo

u

are

cert

ifyi

ng

(pro

mis

ing)

th

at t

her

e is

no

inco

me

to r

epo

rt. I

f lo

cal o

ffic

ials

su

spe

ct t

hat

yo

ur

ho

use

ho

ld in

com

e w

as r

ep

ort

ed in

corr

ectl

y, y

ou

r ap

plic

atio

n w

ill b

e in

vest

igat

ed.

Mar

k h

ow

oft

en e

ach

typ

e o

f in

com

e is

rec

eive

d u

sin

g th

e ch

eck

bo

xes

to t

he

righ

t o

f ea

ch f

ield

.

STEP

1: L

IST

ALL

HO

USE

HO

LD M

EMB

ERS

WH

O A

RE

INFA

NTS

, CH

ILD

REN

, AN

D S

TUD

ENTS

UP

TO

AN

D IN

CLU

DIN

G G

RA

DE

12

Tell

us

ho

w m

any

infa

nts

, ch

ildre

n, a

nd

sch

oo

l stu

den

ts li

ve in

yo

ur

ho

use

ho

ld. T

hey

do

NO

T h

ave

to b

e re

late

d t

o y

ou

to

be

a p

art

of

you

r h

ou

seh

old

. W

ho

sh

ou

ld I

list

he

re?

Wh

en f

illin

g o

ut

this

se

ctio

n, p

leas

e in

clu

de

ALL

me

mb

ers

in y

ou

r h

ou

seh

old

wh

o a

re:

Ch

ildre

n a

ge 1

8 o

r u

nd

er A

ND

are

su

pp

ort

ed w

ith

th

e h

ou

seh

old

’s in

com

e;

In y

ou

r ca

re u

nd

er a

fo

ster

arr

ange

men

t, o

r q

ual

ify

as h

om

ele

ss, m

igra

nt,

or

run

away

yo

uth

;

Stu

den

ts a

tten

din

g La

wre

nce

Pu

blic

Sch

oo

l, re

gard

less

of

age.

A)

List

eac

h c

hild

’s n

ame

. Pri

nt

each

ch

ild’s

nam

e. U

se o

ne

line

of

the

app

licat

ion

fo

r ea

ch c

hild

. If

th

ere

are

mo

re c

hild

ren

pre

sen

t th

an li

nes

on

th

e ap

plic

atio

n, a

ttac

h a

sec

on

d p

iece

of

pap

er w

ith

all

req

uir

ed in

form

atio

n f

or

the

add

itio

nal

ch

ildre

n.

B)

Is t

he

ch

ild a

stu

de

nt

at L

awre

nce

P

ub

lic S

cho

ol ?

Mar

k ‘Y

es’ o

r ‘N

o’ u

nd

er

the

colu

mn

tit

led

“St

ud

ent”

to

tel

l us

wh

ich

ch

ildre

n a

tten

d L

awre

nce

Pu

blic

Sc

ho

ol.

If y

ou

mar

ked

‘Ye

s,’ w

rite

th

e n

ame

of

the

sch

oo

l an

d t

he

grad

e le

vel o

f th

e st

ud

ent

in t

he

‘Sch

oo

l’ an

d ‘G

rad

e’

colu

mn

s to

th

e ri

ght.

C)

Do

yo

u h

ave

an

y fo

ste

r ch

ildre

n?

If a

ny

child

ren

lis

ted

are

fo

ste

r ch

ildre

n, m

ark

the

“Fo

ster

Ch

ild”

bo

x n

ext

to t

he

child

’s n

ame.

If

you

are

ON

LY a

pp

lyin

g fo

r fo

ster

ch

ildre

n, a

fter

fin

ish

ing

STEP

1, g

o t

o S

TEP

4.

Fost

er c

hild

ren

wh

o li

ve w

ith

yo

u m

ay c

ou

nt

as

me

mb

ers

of

you

r h

ou

seh

old

an

d s

ho

uld

be

liste

d o

n

you

r ap

plic

atio

n. I

f yo

u a

re a

pp

lyin

g fo

r b

oth

fo

ster

an

d n

on

-fo

ster

ch

ildre

n, g

o t

o s

tep

3.

D)

Are

an

y ch

ildre

n h

om

ele

ss,

mig

ran

t, o

r ru

naw

ay?

If y

ou

b

elie

ve a

ny

child

list

ed in

th

is

sect

ion

mee

ts t

his

de

scri

pti

on

, m

ark

the

“Ho

mel

ess,

Mig

ran

t,

Ru

naw

ay”

bo

x n

ext

to t

he

child

’s n

ame

and

co

mp

lete

all

step

s o

f th

e ap

plic

atio

n.

Ap

plic

atio

n P

acke

t fo

r Fr

ee a

nd

Re

du

ced

Pri

ce S

cho

ol M

eals

Pag

e 2

3.A

. REP

OR

T IN

CO

ME

EAR

NED

BY

CH

ILD

REN

A

) R

ep

ort

all

inco

me

ear

ne

d o

r re

ceiv

ed

by

child

ren

. R

epo

rt t

he

com

bin

ed g

ross

inco

me

fo

r A

LL c

hild

ren

list

ed in

STE

P 1

in y

ou

r h

ou

seh

old

in t

he

bo

x m

arke

d “

Ch

ild In

com

e.”

On

ly c

ou

nt

fost

er c

hild

ren

’s in

com

e if

yo

u a

re a

pp

lyin

g fo

r th

em t

oge

ther

wit

h t

he

rest

of

you

r h

ou

seh

old

.

Wh

at

is C

hild

In

com

e? C

hild

inco

me

is m

on

ey r

ece

ived

fro

m o

uts

ide

you

r h

ou

seh

old

th

at is

pai

d D

IREC

TLY

to y

ou

r ch

ildre

n. M

any

ho

use

ho

lds

do

no

t h

ave

any

child

inco

me.

3.B

REP

OR

T IN

CO

ME

EAR

NED

BY

AD

ULT

S W

ho

sh

ou

ld I

list

he

re?

Wh

en f

illin

g o

ut

this

sec

tio

n, p

leas

e in

clu

de

ALL

ad

ult

mem

ber

s in

yo

ur

ho

use

ho

ld w

ho

are

livi

ng

wit

h y

ou

an

d s

har

e in

com

e an

d e

xpen

ses,

eve

n if

th

ey a

re n

ot

rela

ted

an

d

even

if t

hey

do

no

t re

ceiv

e in

com

e o

f th

eir

ow

n.

Do

NO

T in

clu

de:

o

P

eop

le w

ho

live

wit

h y

ou

bu

t ar

e n

ot

sup

po

rted

by

you

r h

ou

seh

old

’s in

com

e A

ND

do

no

t co

ntr

ibu

te in

com

e to

yo

ur

ho

use

ho

ld.

o

In

fan

ts, C

hild

ren

an

d s

tud

ents

alr

ead

y lis

ted

in S

TEP

1.

B)

List

ad

ult

ho

use

ho

ld m

em

be

rs’

nam

es.

Pri

nt

the

nam

e o

f ea

ch

ho

use

ho

ld m

em

ber

in t

he

bo

xes

mar

ked

“N

ame

s o

f A

du

lt H

ou

seh

old

M

emb

ers

(Fir

st a

nd

Las

t).”

Do

no

t lis

t an

y h

ou

seh

old

mem

ber

s yo

u li

sted

in

STEP

1. I

f a

child

list

ed in

STE

P 1

has

in

com

e, f

ollo

w t

he

inst

ruct

ion

s in

STE

P

3, p

art

A.

C)

Re

po

rt e

arn

ings

fro

m w

ork

. R

epo

rt a

ll in

com

e fr

om

wo

rk in

th

e “E

arn

ings

fro

m W

ork

” fi

eld

on

th

e ap

plic

atio

n. T

his

is u

sual

ly t

he

mo

ney

rec

eive

d f

rom

wo

rkin

g at

job

s. If

yo

u a

re a

sel

f-em

plo

yed

b

usi

nes

s o

r fa

rm o

wn

er, y

ou

will

rep

ort

yo

ur

net

inco

me.

See

d

etai

led

inst

ruct

ion

s o

n t

he

bac

k o

f th

e ap

plic

atio

n.

Wh

at

if I

am

sel

f-em

plo

yed

? R

epo

rt in

com

e fr

om

th

at w

ork

as

a n

et

amo

un

t. T

his

is c

alcu

late

d b

y su

btr

acti

ng

the

tota

l op

erat

ing

exp

ense

s o

f yo

ur

bu

sin

ess

fro

m it

s gr

oss

rec

eip

ts o

r re

ven

ue.

D)

Re

po

rt in

com

e f

rom

pu

blic

ass

ista

nce

/ch

ild

sup

po

rt/a

limo

ny.

Rep

ort

all

inco

me

that

ap

plie

s in

th

e “P

ub

lic

Ass

ista

nce

/Ch

ild S

up

po

rt/A

limo

ny”

fie

ld o

n t

he

app

licat

ion

. D

o

no

t re

po

rt t

he

cash

val

ue

of

any

pu

blic

ass

ista

nce

ben

efit

s N

OT

liste

d o

n t

he

char

t. If

inco

me

is r

ecei

ved

fro

m c

hild

su

pp

ort

or

alim

on

y, o

nly

rep

ort

co

urt

-ord

ered

pay

men

ts. I

nfo

rmal

bu

t re

gula

r p

aym

ents

sh

ou

ld b

e re

po

rted

as

“oth

er”

inco

me

in t

he

nex

t p

art.

E) R

ep

ort

inco

me

fro

m

pe

nsi

on

s/re

tire

me

nt/

all o

the

r in

com

e.

Rep

ort

all

inco

me

that

ap

plie

s in

th

e “P

ensi

on

s/R

etir

emen

t/ A

ll O

ther

In

com

e” f

ield

on

th

e ap

plic

atio

n.

F) R

ep

ort

to

tal h

ou

seh

old

siz

e.

Ente

r th

e to

tal n

um

ber

of

ho

use

ho

ld

me

mb

ers

in t

he

fiel

d “

Tota

l Ho

use

ho

ld M

em

ber

s (C

hild

ren

an

d

Ad

ult

s).”

Th

is n

um

ber

MU

ST b

e eq

ual

to

th

e n

um

ber

of

ho

use

ho

ld

me

mb

ers

liste

d in

STE

P 1

an

d S

TEP

3. I

f th

ere

are

any

me

mb

ers

of

you

r h

ou

seh

old

th

at y

ou

hav

e n

ot

liste

d o

n t

he

app

licat

ion

, go

bac

k an

d a

dd

th

em. I

t is

ver

y im

po

rtan

t to

list

all

ho

use

ho

ld m

emb

ers,

as

the

size

of

you

r h

ou

seh

old

aff

ects

yo

ur

elig

ibili

ty f

or

fre

e an

d

red

uce

d p

rice

mea

ls.

G)

Pro

vid

e t

he

last

fo

ur

dig

its

of

you

r So

cial

Se

curi

ty N

um

be

r.

An

ad

ult

ho

use

ho

ld m

emb

er m

ust

en

ter

the

last

fo

ur

dig

its

of

thei

r So

cial

Se

curi

ty N

um

ber

in t

he

spac

e p

rovi

ded

. Yo

u a

re

elig

ible

to

ap

ply

fo

r b

enef

its

eve

n if

yo

u d

o n

ot

hav

e a

Soci

al

Secu

rity

Nu

mb

er. I

f n

o a

du

lt h

ou

seh

old

me

mb

ers

hav

e a

Soci

al

Secu

rity

Nu

mb

er, l

eave

th

is s

pac

e b

lan

k an

d m

ark

the

bo

x to

th

e ri

ght

lab

eled

“C

hec

k if

no

SSN

.”

STEP

4: C

ON

TAC

T IN

FOR

MA

TIO

N A

ND

AD

ULT

SIG

NA

TUR

E A

ll a

pp

lica

tio

ns

mu

st b

e si

gn

ed b

y a

n a

du

lt m

emb

er o

f th

e h

ou

seh

old

. By

sig

nin

g t

he

ap

plic

ati

on

, th

at

ho

use

ho

ld m

emb

er is

pro

mis

ing

th

at

all

info

rma

tio

n h

as

bee

n t

ruth

fully

a

nd

co

mp

lete

ly r

epo

rted

. Bef

ore

co

mp

leti

ng

th

is s

ecti

on

, ple

ase

als

o m

ake

su

re y

ou

ha

ve r

ead

th

e p

riva

cy a

nd

civ

il ri

gh

ts s

tate

men

ts o

n t

he

ba

ck o

f th

e a

pp

lica

tio

n.

A)

Pro

vid

e y

ou

r co

nta

ct in

form

atio

n.

Wri

te y

ou

r cu

rren

t ad

dre

ss in

th

e fi

eld

s p

rovi

ded

if t

his

info

rmat

ion

is

avai

lab

le. I

f yo

u h

ave

no

per

man

ent

add

ress

, th

is d

oe

s n

ot

mak

e yo

ur

child

ren

inel

igib

le f

or

free

or

red

uce

d p

rice

sc

ho

ol m

eals

. Sh

arin

g a

ph

on

e n

um

ber

, em

ail a

dd

ress

, or

bo

th is

op

tio

nal

, bu

t h

elp

s u

s re

ach

yo

u q

uic

kly

if w

e n

eed

to

co

nta

ct y

ou

.

B)

Pri

nt

and

sig

n y

ou

r n

ame

an

d

wri

te t

od

ay’s

dat

e. P

rin

t th

e n

ame

of

the

adu

lt s

ign

ing

the

app

licat

ion

an

d t

hat

per

son

sig

ns

in t

he

bo

x “S

ign

atu

re o

f ad

ult

.”

C)

Mai

l Co

mp

lete

d

Form

to

: L

awre

nce

P

ub

lic S

cho

ol,

11

0

McD

on

ald

Dr.

La

wre

nce

KS,

66

04

4

D)

Shar

e c

hild

ren

’s r

acia

l an

d e

thn

ic id

en

titi

es

(op

tio

nal

). O

n t

he

bac

k o

f th

e ap

plic

atio

n, w

e as

k yo

u

to s

har

e in

form

atio

n a

bo

ut

you

r ch

ildre

n’s

rac

e an

d

eth

nic

ity.

Th

is f

ield

is o

pti

on

al a

nd

do

es n

ot

affe

ct

you

r ch

ildre

n’s

elig

ibili

ty f

or

free

or

red

uce

d p

rice

sc

ho

ol m

eals

.

Definitio

n o

f H

ou

se

ho

ld

Me

mb

er:

“A

nyo

ne w

ho is

livin

g w

ith y

ou a

nd s

hare

s

incom

e a

nd e

xp

enses, eve

n

if n

ot re

late

d.”

Childre

n in F

oste

r care

and

childre

n w

ho m

eet th

e

definitio

n o

f H

om

ele

ss

, M

igra

nt

or

Ru

naw

ay a

re

elig

ible

for

free m

eals

. R

ead

Ho

w t

o A

pp

ly f

or

Fre

e a

nd

R

ed

uc

ed

Pri

ce

Sc

ho

ol

Me

als

for

more

info

rmation.

X

X

Are

yo

u u

nsure

what

incom

e to inclu

de h

ere

?

Flip

the p

age a

nd r

evie

w

the c

hart

s title

d “

Sourc

es

of In

com

e”

for

mo

re

info

rmation.

The “

So

urc

es o

f In

com

e

for

Childre

n”

chart

will

help

yo

u w

ith t

he C

hild

Inco

me s

ection.

The “

So

urc

es o

f In

com

e

for

Ad

ults”

chart

will

help

you w

ith t

he A

ll A

dult

House

hold

Mem

bers

section.

Flip

the p

age to learn

how

to r

eport

Incom

e

from

Self E

mplo

ym

ent.

2019

-20

20

Househo

ld A

pp

lica

tion

fo

r F

ree

an

d R

educ

ed

Pri

ce

Scho

ol M

ea

ls

Com

ple

te o

ne

ap

plic

ation

pe

r h

ou

se

hold

. P

lease

use

a p

en

(n

ot

a p

encil)

.

<A

pply

on

line a

t (R

em

ove if

N/A

)>

Ch

ild

’s F

irst

Nam

e

MI

Ch

ild

’s L

ast

Nam

e

Sch

oo

l

Gra

de

If N

O

> G

o to S

TE

P 3

. If

Y

ES

>

Write

a c

ase n

um

ber

he

re th

en g

o to S

TE

P 4

(D

o n

ot com

ple

te S

TE

P 3

)

Write

only

one c

ase n

um

ber

in this

space.

A.

Ch

ild

In

co

me

Som

etim

es c

hild

ren in t

he h

ouse

hold

earn

or

receiv

e incom

e. P

lease

inclu

de t

he

TO

TA

L incom

e r

eceiv

ed b

y a

ll

Househ

old

Mem

bers

lis

ted in S

TE

P 1

here

.

B.

All

Ad

ult

Ho

us

eh

old

Me

mb

ers

(in

clu

din

g y

ou

rself

)

Child

incom

e

$

How

oft

en

?

Lis

t all

Ho

use

hold

Mem

be

rs n

ot lis

ted in S

TE

P 1

(in

clu

din

g y

ours

elf)

even if th

ey d

o n

ot

receiv

e incom

e.

For

each H

ouse

hold

Mem

be

r lis

ted, if th

ey d

o r

eceiv

e incom

e,

report

tota

l gro

ss incom

e (

befo

re t

axe

s)

for

each s

ourc

e in w

hole

dolla

rs (

no c

ents

) only

. If th

ey d

o n

ot

receiv

e incom

e f

rom

an

y s

ou

rce,

write

‘0’. If

yo

u e

nte

r ‘0

’ or

leave a

ny fi

eld

s b

lank,

yo

u a

re c

ert

ifyin

g (

pro

mis

ing)

that th

ere

is n

o inco

me to r

ep

ort

.

Na

me

of

Ad

ult H

ou

se

hold

Me

mb

ers

(F

irst

an

d L

ast)

Earn

ings fro

m W

ork

$

How

oft

en

?

Public

Assis

tance/

Child

Support

/Alim

ony

$

How

oft

en

?

Pensio

ns/R

etir

em

ent/

All

Oth

er

Incom

e

$

How

oft

en

?

$

$

$

$

$

$

$

$

$

$

$

$

To

tal

Ho

useh

old

Me

mb

ers

(C

hil

dre

n a

nd

Ad

ult

s)

Last F

ou

r D

igit

s o

f S

ocia

l S

ecu

rity

Nu

mb

er

(SS

N) o

f

Pri

mary

Wag

e E

arn

er

or

Oth

er

Ad

ult

Ho

useh

old

Mem

ber

Ch

ec

k i

f n

o S

SN

S

TE

P 4

Conta

ct

info

rmati

on a

nd a

dult

sig

natu

re.

Mail c

om

ple

ted f

orm

to:

<in

sert

addre

ss>

“I c

ert

ify (

pro

mis

e)

tha

t all

info

rma

tio

n o

n th

is a

pp

lica

tio

n is t

rue

and

th

at a

ll in

co

me

is r

ep

ort

ed

. I

un

de

rsta

nd

th

at

this

in

form

atio

n is g

ive

n in

con

ne

ctio

n w

ith

th

e r

eceip

t of

Fe

de

ral fu

nd

s,

an

d t

ha

t sch

ool o

ffic

ials

ma

y v

eri

fy (

che

ck)

the

in

form

atio

n.

I a

m a

wa

re t

ha

t if I

purp

osely

giv

e

fals

e info

rma

tio

n,

my c

hild

ren

ma

y lo

se

me

al b

en

efits

, a

nd

I m

ay b

e p

rose

cu

ted

un

de

r a

pp

lica

ble

Sta

te a

nd F

ede

ral la

ws.”

S

tree

t A

ddre

ss (

if a

vaila

ble

) A

pt #

C

ity

Sta

te

Zip

D

aytim

e P

hon

e a

nd

Em

ail

(option

al)

P

rinte

d n

am

e o

f ad

ult s

ignin

g t

he

fo

rm

Sig

natu

re o

f a

dult

Toda

y’s

da

te

ST

EP

1

Lis

t A

LL

Ho

useh

old

Mem

bers

wh

o a

re in

fan

ts, ch

ild

ren

, an

d s

tud

en

ts u

p t

o a

nd

in

clu

din

g g

rad

e 1

2 (

if m

ore

sp

aces a

re r

eq

uir

ed

fo

r ad

dit

ion

al n

am

es, att

ach

an

oth

er

sh

eet

of

pap

er)

S

TE

P 2

D

o a

ny H

ou

seh

old

Mem

bers

(in

clu

din

g y

ou

) cu

rren

tly p

art

icip

ate

in

on

e o

r m

ore

of

the f

ollo

win

g a

ssis

tan

ce p

rog

ram

s:

Fo

od

Assis

tan

ce, T

AF

, o

r F

DP

IR?

ST

EP

3

Report

Incom

e for A

LL H

ouse

hold

Mem

bers

(Skip

this

ste

p if

you a

nsw

ere

d ‘Yes’

to S

TEP 2

)

Check all that apply

Ca

se

Nu

mb

er:

Wee

kly

Bi-W

eekl

y 2x

Mon

th

Mon

thly

Wee

kly

Bi-W

eekl

y 2x

Mon

th M

onth

ly

Wee

kly

Bi-W

eekl

y 2x

Mon

th M

onth

ly

Wee

kly

Bi-W

eekl

y 2x

Mon

th

Mon

thly

X

X

X

S

tud

en

t?

Ye

s

No

Foste

r

H

om

ele

ss,

Child

M

igra

nt,

R

unaw

ay

In

co

me f

rom

Self

Em

plo

ym

en

t: S

elf-e

mplo

ye

d p

ers

ons m

ay u

se

incom

e t

ax r

ecord

s f

or

the

pre

ce

din

g

cale

nda

r ye

ar

as a

base t

o p

roje

ct th

e c

urr

ent

ye

ar’s n

et in

com

e,

unle

ss t

he c

urr

en

t m

onth

ly incom

e p

rovid

es

a m

ore

accura

te m

easure

. R

ep

ort

inco

me d

erive

d fro

m th

e b

usin

ess v

en

ture

less o

pe

rating c

osts

incurr

ed in

the g

ene

ration o

f th

at

incom

e. D

ed

uctions f

or

pe

rso

nal e

xpen

ses s

uch a

s inte

rest

on

hom

e p

aym

ents

, m

edic

al e

xp

enses,

an

d o

the

r sim

ilar

no

n-b

usin

ess d

eduction

s a

re n

ot

allo

wed

in r

edu

cin

g g

ross b

usin

ess

incom

e.

Additio

nal in

com

e f

rom

oth

er

kin

ds o

f em

plo

ym

ent m

ust b

e t

rea

ted a

s s

ep

ara

te a

nd a

pa

rt f

rom

the

in

com

e g

enera

ted o

r lo

st

from

yo

ur

busin

ess v

en

ture

. F

or

exam

ple

, if y

ou o

pe

rate

d a

busin

ess a

t a n

et lo

ss,

but

held

additio

nal em

plo

ymen

t fo

r w

hic

h a

sala

ry w

as r

eceiv

ed, th

e incom

e fo

r p

urp

ose

s o

f a

pply

ing f

or

red

uce

d p

rice

or

free m

eals

would

be t

he incom

e f

rom

the

sala

ry o

nly

. T

he lo

ss fro

m th

e b

usin

ess c

an

not

be

ded

ucte

d f

rom

a p

ositiv

e incom

e e

arn

ed in o

ther

em

plo

yment.

F

or

purp

oses o

f th

is a

pplic

atio

n, it is n

ot possib

le to

re

po

rt a

neg

ative

incom

e fro

m a

ny b

usin

ess v

entu

re.

The le

ast in

com

e p

ossib

le is z

ero

(no incom

e).

T

he n

ece

ssa

ry in

form

atio

n fo

r arr

ivin

g a

t allo

wable

in

com

e f

rom

priva

te b

usin

ess o

pe

ration m

ay b

e take

n fro

m y

our

most

rece

nt U

.S.

Indiv

idual In

com

e T

ax R

etu

rn -

Fo

rm 1

040,

Sched

ule

1. A

dd t

og

eth

er

the a

mo

unts

re

port

ed

on th

e f

ollo

win

g lin

es:

LIN

E 1

2

$__________

_____ B

usin

ess I

nco

me o

r (L

oss)

LIN

E 1

3

$__________

_____ C

apital G

ain

or

(Loss)

LIN

E 1

4

$__________

_____ O

ther

Gain

s o

r (L

osses)

LIN

E 1

7

$__________

_____ R

enta

l re

al esta

te, ro

yaltie

s, part

ners

hip

s, S

corp

ora

tions, tr

usts

, etc

. LIN

E 1

8

$__________

_____ F

arm

Incom

e o

r (L

oss)

T

OT

AL

$__________

_____ G

ross A

nnual In

com

e B

efo

re A

ny D

ed

uctions.

C

om

pute

d M

onth

ly Incom

e

$__________

_____ G

ross A

nnual In

com

e ÷

12 =

Com

pute

d M

onth

ly I

ncom

e. R

ep

ort

in S

tep 3

.

W

e a

re r

equir

ed t

o a

sk for

info

rmation a

bo

ut

yo

ur

child

ren’s

ra

ce a

nd e

thnic

ity. T

his

info

rma

tion

is im

po

rta

nt

an

d h

elp

s t

o m

ake s

ure

we

are

fully

serv

ing o

ur

com

munity.

Respo

ndin

g t

o t

his

se

ctio

n is o

ption

al a

nd d

oes n

ot

affect

yo

ur

child

ren’s

elig

ibili

ty f

or

fre

e o

r re

du

ced

price m

eals

. If

yo

u d

o n

ot sele

ct ra

ce o

r eth

nic

ity,

on

e w

ill b

e s

ele

cte

d fo

r yo

u b

ased o

n v

isu

al o

bse

rva

tion

.

Eth

nic

ity (check

one):

Race (ch

eck

one o

r m

ore

):

H

ispa

nic

or

Latin

o

N

ot H

ispa

nic

or

Latin

o

A

merican

In

dia

n o

r A

laskan

Native

Asia

n

B

lack o

r A

fric

an

Am

erican

Na

tive H

aw

aiia

n o

r O

the

r P

acifi

c Isla

nde

r

White

The R

ich

ard

B.

Ru

ss

ell N

ati

on

al S

ch

oo

l L

un

ch

Ac

t re

quir

es th

e in

form

atio

n o

n t

his

ap

plic

ation.

You

do n

ot

have to

giv

e th

e info

rmatio

n,

but if y

ou d

o n

ot,

we c

an

no

t a

pp

rove y

our

child

fo

r fr

ee o

r re

duced p

rice m

eals

. Y

ou m

ust in

clu

de the la

st fo

ur dig

its o

f th

e s

ocia

l security

num

ber

of th

e p

rim

ary

wage e

arn

er

or

oth

er

adult

household

mem

ber

who

sig

ns the a

pplic

atio

n. T

he s

ocia

l secu

rity

num

ber

is n

ot

req

uir

ed w

he

n y

ou a

pply

on

beh

alf o

f a

foste

r child

or

yo

u lis

t a F

oo

d A

ssis

tance (

FA

) T

em

po

rary

Assis

tan

ce fo

r F

am

ilies (

TA

F)

Pro

gra

m o

r F

ood D

istr

ibution P

rog

ram

on I

ndia

n R

eserv

ations (

FD

PIR

) case n

um

be

r or

oth

er

FD

PIR

id

entifier

for

yo

ur

child

or

whe

n y

ou in

dic

ate

tha

t th

e a

dult h

ou

seh

old

mem

ber

sig

nin

g t

he

applic

atio

n d

oe

s n

ot h

ave a

socia

l se

curi

ty

num

be

r. W

e w

ill u

se y

ou

r in

form

atio

n t

o d

ete

rmin

e if

yo

ur

child

is e

ligib

le fo

r fr

ee o

r re

duced p

rice m

eals

, a

nd

for

adm

inis

tra

tion

and e

nfo

rcem

ent

of

the lunch a

nd b

reakfa

st

pro

gra

ms. W

e M

AY

sh

are

yo

ur

elig

ibili

ty

info

rmatio

n w

ith e

ducatio

n,

he

alth,

an

d n

utr

itio

n p

rogra

ms t

o h

elp

th

em

evalu

ate

, fu

nd

, o

r d

ete

rmin

e b

enefits

for

their

pro

gra

ms,

au

dito

rs f

or

pro

gra

m r

evie

ws,

an

d la

w e

nfo

rcem

ent

offic

ials

to

help

th

em

look into

vio

latio

ns o

f pro

gra

m r

ule

s.

In a

cco

rda

nce w

ith

Fed

era

l civ

il rig

hts

law

an

d U

.S. D

epart

ment of A

griculture

(U

SD

A) civ

il rig

hts

re

gula

tion

s a

nd

polic

ies, th

e U

SD

A, its A

gen

cie

s, o

ffic

es, a

nd e

mplo

ye

es, a

nd in

stitu

tion

s p

art

icip

ating in o

r adm

inis

teri

ng U

SD

A

pro

gra

ms a

re p

rohib

ited

fro

m d

iscrim

ina

ting b

ased o

n r

ace, colo

r, n

ation

al o

rigin

, se

x,

dis

abili

ty, age

, o

r re

prisal

or

reta

liation

fo

r pri

or

civ

il righ

ts a

ctivity in a

ny p

rog

ram

or

activity c

on

ducte

d o

r fu

nd

ed b

y U

SD

A.

Pers

ons w

ith d

isabili

ties w

ho r

equire a

ltern

ative m

eans o

f com

munic

ation for

pro

gra

m info

rmatio

n (

e.g

. B

raill

e,

larg

e p

rint,

audio

tape,

Am

erican S

ign L

anguage,

etc

.),

should

conta

ct

the A

gency

(Sta

te o

r lo

cal) w

here

they

applie

d f

or

benefits

. In

div

iduals

who a

re d

eaf, h

ard

of

hearing o

r have s

peech d

isabili

ties m

ay

conta

ct

US

DA

th

rough th

e F

edera

l R

ela

y S

erv

ice at

(800)

877-8

339.

Additio

nally

, pro

gra

m in

form

ation

m

ay

be m

ade

availa

ble

in la

nguages o

ther

than E

nglis

h.

To fi

le a

pro

gra

m c

om

pla

int of dis

crim

inatio

n, com

ple

te the U

SD

A P

rogra

m D

iscrim

ination C

om

pla

int F

orm

, (A

D-3

027)

found o

nlin

e a

t: h

ttp://w

ww

.ascr.

usda.g

ov/c

om

pla

int_

filin

g_cust.htm

l, a

nd a

t an

y U

SD

A o

ffic

e, o

r w

rite

a le

tter

addre

ssed

to U

SD

A a

nd p

rovid

e in

the le

tter

all

of th

e in

form

ation r

equeste

d in

the form

. T

o

request a c

opy

of th

e c

om

pla

int fo

rm,

call

(866)

632-9

992.

Subm

it y

our

com

ple

ted form

or

letter to

US

DA

by:

(1)

Mail:

U

.S. D

epart

ment of A

griculture

Offic

e o

f th

e A

ssis

tan

t S

ecre

tary

for

Civ

il R

ights

140

0 In

de

pe

nd

ence A

ven

ue

, S

W

Washin

gto

n, D

.C. 2

02

50

-94

10

(2)

Fa

x:

(20

2)

69

0-7

44

2;

or

(3)

Em

ail:

pro

gra

m.in

take@

usda

.go

v.

This

institu

tio

n is a

n e

qual op

po

rtu

nity p

rovid

er.

Tota

l In

com

e: $

__

__

__

___

__

_

H

ow

Oft

en (

Cir

cle

On

e):

W

B

W 2

M M

M

ultip

le=

Ye

arl

y

H

ouse

hold

Siz

e:

__

__

__

__

Cate

go

rical E

ligib

ility

(F

A, T

AF

, F

DP

IR, F

oste

r)

Elig

ibili

ty:

Fre

e

OR

Redu

ced

Price

O

R

D

enie

d

Note

s:_

___

__

__

___

__

__

__

___

__

__

__

___

__

__

___

__

__

__

___

__

__

__

___

__

____

___

__

__

___

__

__

__

___

__

__

__

___

__

____

__

__

___

__

__

__

___

__

__

__

___

__

__

Dete

rmin

ing O

ffic

ial’s

Sig

natu

re:

A

ppro

val/D

enia

l D

ate

:

N

otificatio

n D

ate

:

Pro

ce

ss

or’

s I

nit

ials

:

Co

nfi

rmin

g O

ffic

ial’

s S

ign

atu

re (

ON

LY

fo

r ap

pli

ca

tio

ns t

o b

e v

eri

fie

d):

R

evie

w D

ate

:

So

urc

es o

f In

co

me f

or

Ch

ild

ren

So

urc

es o

f Ch

ild In

com

e E

xam

ple

(s)

Earn

ings f

rom

work

A c

hild

has a

re

gula

r fu

ll o

r p

art

-tim

e jo

b w

here

th

ey

earn

a s

ala

ry o

r w

ages

S

ocia

l S

ecuri

ty

- D

isabili

ty P

aym

ents

- S

urv

ivor’s B

en

efits

A c

hild

is b

lind o

r dis

able

d a

nd

receiv

es

Socia

l S

ecurity

benefits

A P

are

nt is

dis

able

d, re

tired, or deceased, and th

eir c

hild

re

ceiv

es

Soci

al S

ecurity

benefit

s

Incom

e fro

m p

ers

on o

uts

ide t

he

hou

seh

old

A frie

nd o

r e

xte

nd

ed

fam

ily m

em

ber

regula

rly g

ives a

child

spe

ndin

g m

one

y

Incom

e fro

m a

ny o

the

r so

urc

e

A c

hild

receiv

es r

eg

ula

r in

com

e fro

m a

priva

te p

ensio

n

fun

d, a

nn

uity,

or

trust

INS

TR

UC

TIO

NS

S

ou

rces o

f In

co

me

OP

TIO

NA

L

Ch

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acia

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d E

thn

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titi

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Do

no

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ll o

ut

Fo

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ch

oo

l U

se O

nly

– A

nn

ual In

co

me C

on

vers

ion

: W

eekly

x 5

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i-W

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wic

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Mo

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wa

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sh

bon

use

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Net in

com

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self-

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plo

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arm

or

busin

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If y

ou a

re in t

he U

.S.

Mili

tary

:

Basic

pa

y a

nd

cash b

on

use

s (

do

NO

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om

bat p

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FS

SA

or

priva

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tate

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on

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sup

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Str

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enefits

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inclu

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retire

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)

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pensio

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fits

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vestm

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enta

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com

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• R

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outs

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seh

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Lawrence Public Schools

Consent for Disclosure

Sharing Information with Other Programs

Dear Parent/Guardian:

You do not have to sign or send in this form to get reduced price or free Child Nutrition Program Benefits for your

children. If you do not sign the Consent for Disclosure, it will not affect eligibility for or participation in the Child

Nutrition Programs.

To save you time and effort, information about your children’s eligibility for reduced price or free Child Nutrition

Program Benefits may be shared with other programs for which your children may qualify. For the programs listed

below, we must have your permission to share your information.

No, I DO NOT want information about my children’s eligibility for Child Nutrition Program benefits shared with

any of these programs.

Yes, I DO want school officials to share information about my children’s eligibility for Child Nutrition Program benefits with the programs I have checked below.

Activity Trip Transportation Activity Tickets Student Fees – Books, Materials, Tech Graduation Fees: Cap and Gown

Instrument Maintenance Fee Scholarships and/or Internships

Participation Fees

Co- Curricular Fees

Course Fees

If you checked yes to any or all of the boxes above, fill out the form below. Your information will be shared only with

the programs you checked.

Child’s Name: _________________________ School: _________________________

Child’s Name: _________________________ School: _________________________

Child’s Name: _________________________ School: _________________________

Child’s Name: _________________________ School: _________________________

Child’s Name: _________________________ School: _________________________

Signature of Parent/Guardian_________________________ (required) Date: ________________

Printed Name: _____________________________________________________

Address: _________________________________________________________

For more information, you may call:

Food Services Department at (785)832-5000

Return this form to:

Food Services Office, 110 McDonald Dr. Lawrence, KS 66044

This institution is an equal opportunity provider

Consent for Disclosure – 4/2019