![](media/image1.png){width="1.0402777777777779in"
height="1.2486111111111111in"}[Tsab Ntawv Teev Npe Thov Mov Noj Dawb
Thiab Luv Nqi Mov Tom Tsev Kawmntawv Thiab Cov Ntawv Txheeb Xyuas Qhov
Tseeb]{.smallcaps}

# 

# XYOO KAWM NTAWV \_\_\_\_\_-\_\_\_\_\_

# Kev Qhia Ua Rau Cov Chaw Tswjfwm Txog Cov Cheeb Tsam Tsev Kawmntawv 

Tsab ntawv no muaj:

Cov ntaubntawv uas **tseev** kom *yuav tsum* muab rau cov tsevneeg:

-   Tsab ntawv rau cov tsevneeg

-   Tsab Ntawv Teev Npe Thov Mov Noj Dawb thiab Luv Nqi Mov Tom Tsev
    Kawmntawv

Cov ntaubntawv qhia txog saib puas muaj cuab kav tau txais:

-   Tsab Ntawv Ceebtoom Tias Raug Xaiv Kuaj Saib Puas Muaj Cuab Kav Tau
    Txais

-   Tsab Ntawv Qhia Tias Xyuas Tag Es Pomzoo Li Cas

Ntauntawv Teev Npe Txheeb Ze Lwm Yam Uas **Nyob Ntawm Ywj Siab Xav Ua**
Uas *Tejzaum* Muab Rau Cov Tsevneeg:

-   Muab tej ntaubntawv qhia rau Medicaid/SCHIP

-   Muab tej ntaubntawv qhia rau tej Programs Lwm Yam

Cov nploojntawv mas ua kom haum sau rau daim ntawv loj li 8½" nrog rau
11". Qee cov nploojntawv tejzaum kuj sau rau sab pem hauv ntej thiab
nram qab tib si. Koj yuav tsum xyuas saib dab tsi yog tej kev pab muaj
nyob rau ntawm koj lub tsev kawmntawv, xwsli tej nyuag kev noj haus dog
dig thaum lawb ntawv. **\[Kem ntawv dub muaj ob sab ntug thaiv\]** qhia
tias yog qhov chaw koj yuav tsum sau lo lus meej meej txog qhov chaw
tswjfwm txog cov cheeb tsam tsev kawmntawv. Pivxamli, koj yuav tsum qhia
koj qhov chaw tswjfwm txog cov cheeb tsam tsev kawmntawv tus xovtooj
nabnpawb hu dawb uas siv hu pab txheeb xyuas txog tej ntaubntawb. Yog
cov ntaubntawv no tseem tsis tau raug kho kom muaj koj lub Xeev lub npe
siv rau qhov Kev Pab Ib Nyuag Ntu Rau Tseevneeg Txom Nyem (Temporary
Assistance to Needy Family (TANF)), rau Kev Pab Kho Mob Rau Cov Menyuam
Hauv Lub Xeev (State Children Health Insurance Program (SCHIP)), lossis,
yog muaj, los siv rau Kev Pab Faib Mov Pub Rau Hauv Khab Zos (Food
Disribution on Indian Reservations (FDPIR)), mas koj yuav tsum sau qhov
lus no rau ntawm cov chaw uas qhia tias kom sau. Yog koj hloov kho dab
tsi ntxiv, koj yuav tsum xa tsab ntawv teev npe tag nrho mus rau qhov
chaw ua haujlwm ntawm koj lub Xeev kom lees paub pom zoo.

Tsab qauv ntawv teev npe no muaj cov ntaubntawv txog tej nqi vaj tsev
uas pab nyob rau hauv Txoj Kev Pab Chaw Nyob Rau Tub Rog (Military
Housing Privatization Initiative) uas tsis xam txog. Yog qhov no tsis
muaj nyob rau hauv koj qhov chaw tswjfwm txog cov cheeb tsam tsev
kawmntawv, mas thov koj hloov kho kom yog.

Yog koj muaj lus dab tsi xav nug, thov hu cuag:

**\[State agency address\]\]**

**\[Insert School District Letterhead\]**

Txog Rau Niam thiabTxiv/ Tus Saib Xyuas:

*Menyuam yau yuav tsum tau noj zoo thiaj kawm tau ntawv*. ***\[Name of
School\]*** *txhua txhua hnub yeej muaj mov noj tej zoo rau cov menyuam.
Pluag tshais raug nyiaj **\[\$\]**; pluag sus raug nyiaj **\[\$\].** Koj
tus menyuam tejzaum muaj cuab kav tau txais mov noj dawb lossis luv nqi
mov. Tus nqi luv noj mov yog **\[\$\]** rau pluag tshais thiab
**\[\$\]** rau pluag su.*

**1. Kuv puas yuav tsum ua ntawv teev npe rau txhua txhua tus menyuam?**
Tsis tas ua rau txhua tus. Ua tsab ntawv teev npe thov noj mov dawb
lossis luv nqi mov xwb. [Siv tib Tsab Ntawv Teev Npe Thov Mov Noj Dawb
thiab Luv Nqi Mov Tom Tsev kawmntawv rau tag nrho cov menyuam hauv koj
tsevneeg]{.underline}. Tsab ntawv twg ua tsis tiav tag tag mas peb tsis
muaj cuabkav pomzoo tias kam, vim li ntawd yuav tsum teb tag nrho cov
lus tseev tias kom yuav tsum teb. **Xa tsab ntawv teev npe ua tiav tag
tuaj rau: \[name, address, phone number\].**

**2. Leejtwg thiaj tau txais mov noj dawb?** Cov menyuam ntawm cov
tsevneeg uas tau txais Food Stamps lossis TANF thiab feem ntau cov
menyuam uas txais los tu txawm koj khwv tau nyiaj npaum cas los xij.
Tsis tag li, koj cov menyuam muaj cuab kav tau txais mov noj dawb yog
koj tsev neeg khwv tau nyiaj ncaj li Tus Nqi Nyiaj Tseemfwv Tebchaws
Phua Tseg tias kam pub dawb.

**3. Cov menyuam tsis muaj vajtsev nyob, khiav tawm ntawm tsev thiab cov
menyuam uas nws tsevneeg ua zog ib sij tsim ib qho chaw rau ib qho puas
muaj cuab kav tau txais mov noj dawb?** Thov hu rau **\[School, homeless
liaison lor migrant coordinator\]** xyuas saib koj tus lossis cov
menyuam puas muaj cuab kav tau txais, yog tsis tau muaj leejtwg qhia rau
koj tias lawv puas muaj cuab kav tau txais mov noj dawb.

**4. Leejtwg thiaj muaj cuabkav tau txais qhov luv nqi mov?** Koj cov
menyuam muaj cuabkav tau txais qhov luv nqi mov yog koj tsevneeg khwv
tau nyiaj ncaj li tus nqi phua tseg tias kam pub tus nqi luv mov uas
qhia nyob rau ntawm Tseemfwv Lub Roojntawv Txog Nyiaj, uas muaj nyob rau
ntawm tsab ntawv teev npe.

**5. Kuv puas yuav tsum ua ntaubntawv teev npe thov yog tias kuv tau
txais ntawv tuaj tom tsev kawmntawv hais tias kuv cov menyuam tau txais
mov noj dawb lossis luv nqi mov noj?** Koj yuav tsum ua twb zoo nyeem
daim ntawv thiab ua raws li tsab ntawv qhia. Hu rau lub tsev kawmntawv
ntawm tus xovtooj **\[phone number\]** yog koj muaj lus dab tsi xav nug.

**6. Kuv tau txais WIC. Ua li kuv tus lossis cov menyuam puas muaj
cuabkav tau txais mov noj dawb?** Cov menyuam ntawm cov tsevneeg uas tau
txais WIC [tejzaum]{.underline} kuj muaj cuabkav tau txais mov noj dawb
lossis luv nqi mov noj. Thov ua tsab ntawv teev npe.

**7. Cov ntauntawv kuv ua puas yuav raug muab kuaj xyuas?** Raug,
tejzaum peb kuj yuav kom koj xa ntaubntawv tuaj ua povthawj.

**8. Yog tamsim no kuv tsis muaj cuabkav tau txais, ua li lwm hnub kuv
puas muaj cuabkav teev npe thov dua?** Muaj, koj muaj cuabkav thov dua
txhua txhua lub sijhawm tsev kawmntawv tseem qhib yog tias cov neeg hauv
koj tsev muaj coob dua qub, nyiaj txiag khwv tau tsawg dua, lossis yog
koj pib tau txais nyiaj Food Stamps, TANF lossis lwm yam kev pab. Yog
koj poob haujlwm, tejzaum koj cov menyuam muaj cuabkav tau txais mov noj
dawb lossis luv nqi mov noj.

**9. Yog kuv tsis pomzoo raws li tsev kawmntawv tau txiav txim txog kuv
tsab ntawv teev npe ne ho yuav ua li ca?** Koj yuav tsum tham nrog cov
neeg ua haujlwm rau tsev kawmntawv. Koj kuj muaj cuabkav hu lossis sau
ntawv mus rau **\[name, address, phone number\]** kom luag mloog txog
koj cov lus.

**10. Kuv puas muaj cuabkav teev npe thov yog hauv kuv tsev muaj tus
tsis yog xeem xaj U.S.?** Muaj cuabkav. Koj lossis koj cov menyuam tsis
tas yog xeem xaj U.S. los yeej muaj cuabkav tau txais mov noj dawb
lossis luv nqi mov noj.

**11. Leejtwg thiaj raug xam tias yog nyob hauv kuv tsev?** Koj yuav
tsum xam tag nrho cov neeg nyob hauv koj tsev, txawm lawv txheeb ze
thiab tsis txheeb los xij (xws li pog yawg, niamtais yawmtxiv, kwvtij
neejtsa, lossis phoojywg tej). Koj yuav tsum xam koj tus kheej thiab tag
nrho cov menyuam nyob nrog koj.

**12. Yog kuv qhov nyiaj khwv tau los pheej ntau sib txawv ne yuav ua li
cas?** Sau tus nqi nyiaj uas koj nquag khwv tau. Pivxamli, yog koj nquag
tau li \$1000 tauj ib hlis, tiamsis lub hlis tag los koj khaj haujlwm me
ntsis es koj tau txais \$900 xwb, mas koj yuav tsum sau tias koj tau
\$1000 tauj ib hlis. Yog koj nquag tau nyiaj ua haujlwm tshaj, mas koj
yuav tsum qhia rau, tiamsis yog ntev ntev mam muaj tau ces tsis tas sau
rau.

**13. Peb yog nyob rau hauv cov tub rog, ua li peb puas xam cov nyiaj
luag pab tsev nyob rau peb ua ib qhov nyiaj peb khwv tau los?** Yog qhov
luag pab rau tsev nyob ntawd yog los ntawm qhov kev pab Military
Privatization Initiative, ces txhob xam qhov nyiaj pab tsev ntawd tias
yog qhov nyiaj khwv tau los. Txhua yam nyiaj txiag lwm yam uas tau txais
yuav tsum muab xam nrog rau qhov nyiaj tau nkag los tag nrho.

If you have other questions or need help, call **\[phone number\].**

Yog koj muaj lus nug dab tsi lossis toobkam pab dab tsi, mas hu rau
**\[phone number\].**

Ua Tsaug

**\[signature\]**

**LUS QHIA UA NTAWV THOV**

+-----------------------------------------------------------------------+
| **Yog koj tsevneeg tau txais nyiaj FOOD STAMPS LOSSIS TANF, mas ua    |
| raws li cov lus qhia no:**                                            |
|                                                                       |
| **Qhov 1:** Sau menyuam cov npe, tsev kawmntawv, qib ntawv, thiab tus |
| nabnpawb tau txais nyiaj Food Stamp lossis TANF pab.                  |
|                                                                       |
| **Qhov 2:** Kos tus cim rau tas ntawv uas yog raws li muaj.           |
|                                                                       |
| **Qhov 3:** Hla qhov no.                                              |
|                                                                       |
| **Qhov 4:** Hla qhov no.                                              |
|                                                                       |
| **Qhov 5:** Xee npe rau daim ntawv. Tsis muaj tus nabnpawb xaus-saus  |
| los tsis ua li cas.                                                   |
|                                                                       |
| **Qhov 6:** Teb lo lus nug no yog koj xav teb.                        |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Kos cim rau tas ntawv ua yog raws li muaj thiab hu rau \[your       |
| school, homeless liaison, migrant coordinator\].**                    |
|                                                                       |
| **Ua tsab ntawv raws li cov lus qhia hauv qab no rau TAG NRHO COV     |
| NEEG LWM TUS HAUV KOJ TSEVNEEG**                                      |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Yog koj ua ntawv thov rau tus MENYUAM TXAIS LOS TU, mas ua raws li  |
| cov lus qhia no:**                                                    |
|                                                                       |
| **Qhov 1:** Siv ib daim ntawv thov rau ib tug menyuam txais los tu.   |
| Sau tus menyuam lub npe, tsev kawmntawv, thiab qib ntawv.             |
|                                                                       |
| **Qhov 2:** Hla qhov no.                                              |
|                                                                       |
| **Qhov 3:** Kos cim rau tas ntawv thiab sau qhov nyiaj ib hlis twg    |
| tau txais siv rau tus menyuam, yog tau txais.                         |
|                                                                       |
| **Qhov 4:** Hla qhov no.                                              |
|                                                                       |
| **Qhov 5:** Xee npe rau daim ntawv. Tsis muaj tus nabnpawb xaus-saus  |
| los tsis ua li cas.                                                   |
|                                                                       |
| **Qhov 6:** Teb lo lus nug no yog koj xav teb.                        |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **TAG NRHO COV NEEG LWM TUS HAUV KOJ TSEVNEEG, xam cov tsevneeg tau   |
| txais WIC nrog, mas ua raws li cov lus qhia no:**                     |
|                                                                       |
| **Qhov 1:** Sau txhua tus menyuam lub npe, tsev kawmntawv, thiab qib  |
| ntawv.                                                                |
|                                                                       |
| **Qhov 2:** Kos tus cim rau tas ntawv uas yog raws li muaj.           |
|                                                                       |
| **Qhov 3**: Hla qhov no.                                              |
|                                                                       |
| **Qhov 4:** Ua raws li cov lus qhia no uas qhia txog tag nrho cov     |
| nyiaj tsevneeg khwv tau lub hli dhau los.                             |
|                                                                       |
| > **Kem 1 -- Lub npe**: Sau lub npe hu thiab lub xeem rau **txhua     |
| > tus** neeg nyob hauv koj tsev, txheeb ze thiab tsis txheeb los xij  |
| > (xws li pog yawg, niamtais yawmtxiv, kwvtij neejtsa, lossis         |
| > phoojywg tej). Koj yuav tsum xam koj thiab tag nrho koj cov menyuam |
| > uas nyob nrog koj. Siv lwm daim ntawv rau npe ntxiv yog koj         |
| > toobkam.                                                            |
| >                                                                     |
| > **Kem 2** -- **Qhov nyiaj khwv tau tag nrho lub hli dhau los thiab  |
| > nquag tau txais tsawg zaus.** Ntawm tus neeg lub npe ib sab sau tus |
| > nqi nyiaj lub hli tag los uas tau txais los ntawm qhov chaw ntawd   |
| > los, thiab nquag tau txais tsawg zaus. Pivxamli, *Nyiaj tau ntawm   |
| > haujlwm los:* Sau **qhov nyiaj khwv tau tag nrho** uas tus neeg     |
| > ntawd ua haujlwm tau rau. Qhov no tsis zoo tib yam li qhov nqa kiag |
| > los tsev. **Qhov nyiaj khwv tau tag nrho mas yog qhov nyiaj khwv    |
| > tau ua ntej txiav them se thiab raug txiav tawm mus rau lwm yam.**  |
| > Qhov nyiaj no muaj sau nyob rau ntawm daim tw tshev, lossis koj tus |
| > nais yeej muaj cuab kav qhia tau rau koj. [Ntawm kiag qhov nyiaj ib |
| > sab, sau qhia saib tus neeg nquag tau txais qhov nyiaj tsawg zaus   |
| > (ib as-thiv ib zaug, ob as-thiv ib zaug, ob zaug tauj ib hlis,      |
| > lossis ib hlis ib zaug).]{.underline} *Tag nrho cov nyiaj lwm yam   |
| > tau los:* Sau qhov nyiaj tus neeg tau txais lub hli dhau los ntawm  |
| > welfare, nyiaj pab menyuam, nyiaj cov niamtxiv sib nraug xa tuaj    |
| > yug tus pojniam lossis tus txiv, (kem ob) nyiaj them rau neeg so    |
| > haujlwm los xiam-oob-khab, nyiaj laus, nyiaj saus-xaus (kem peb),   |
| > thiab TAG NRHO TEJ LWM YAM UA TAU LOS (kem plaub). Nyob rau kem Tag |
| > Nrho Lwm Yam, sau tej nyiaj xws li nyiaj pab rau neeg muab mob ua   |
| > tsis tau haujlwm, nyiaj poob haujlwm, nyiaj them rau cov tsis txaus |
| > siab ua haujlwm, nyiaj SSI, nyiaj pab tub rog (VA benefits), nyiaj  |
| > mob ua tsis tau haujlwm, thiab tej nyiaj uas cov neeg tsis nyob ib  |
| > tse nrog koj muab rau koj, thiab TEJ NYIAJ LWM YAM uas tau los.     |
| > Yuav tsum qhia tej nyiaj tau ka lai los ntawm ua lagluam, ua teb    |
| > lossis xoj tsev rau . [Ntawm qhov nyiaj ib sab sau qhia saib nquag  |
| > tau tsawg zaus]{.underline}. Yog koj yog cov luag pab nqi tsev rau  |
| > tej tub rog nyob (Military Housing Privatization Initiative), mas   |
| > koj txhob muab tej nqi nyiaj pab tsev no sau rau.                   |
| >                                                                     |
| > **Kem 3 -- Kos tus cim rau yog tsis muaj nyiaj tau los:** Yog tus   |
| > neeg ntawd tsis muaj nyiaj qhov twg nkag los li, ces kom tus cim    |
| > rau tas ntawm.                                                      |
| >                                                                     |
| > **Qhov 5:** Tus neeg muaj hnub nyoog hauv lub tsev yuav tsum xee    |
| > daim ntawv thiab sau nws tus nabnpawb xaus-saus rau, lossis kos tus |
| > cim rau tas ntawv yog nws tsis muaj.                                |
|                                                                       |
| **Qhov 6:** Teb lo lus no yog koj txaus siab xav teb.                 |
+-----------------------------------------------------------------------+

**TSEV NEEG TSAB NTAWV TEEV NPE THOV MOV NOJ DAWB THIAB LUV NQI MOV TOM
TSEV KAWMNTAWV**

+-------------------+---+---------+-----+----+---+----------+----------+---+
| **Qhov 1. Menyuam |   |         |     |    |   |          |          |   |
| hauv Tsev         |   |         |     |    |   |          |          |   |
| Kawmntawv         |   |         |     |    |   |          |          |   |
| (Menyuam txais    |   |         |     |    |   |          |          |   |
| los tu mas yuav   |   |         |     |    |   |          |          |   |
| tsum ua ib daim   |   |         |     |    |   |          |          |   |
| rau ib tug)**     |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
| Tag nrho cov      |   | Npe     |     | Q  |   | Food     |          |   |
| menyuam hauv tsev |   | Tsev    |     | ib |   | Stamp    |          |   |
| kawmntawv cov npe |   | Ka      |     | N  |   | lossis   |          |   |
| (Npe tis, Tus     |   | wmntawv |     | ta |   | TANF tus |          |   |
| ntawv rau lub npe |   |         |     | wv |   | case \#  |          |   |
| ua si (Middle     |   |         |     |    |   | (yog     |          |   |
| Initial), Lub     |   |         |     |    |   | muaj).   |          |   |
| xeem)             |   |         |     |    |   | **Hla    |          |   |
|                   |   |         |     |    |   | mus teb  |          |   |
|                   |   |         |     |    |   | Qhov 5   |          |   |
|                   |   |         |     |    |   | yog koj  |          |   |
|                   |   |         |     |    |   | sau Food |          |   |
|                   |   |         |     |    |   | Stamp    |          |   |
|                   |   |         |     |    |   | lossis   |          |   |
|                   |   |         |     |    |   | TANF tus |          |   |
|                   |   |         |     |    |   | case \#  |          |   |
|                   |   |         |     |    |   | rau**    |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
|                   |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
|                   |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
|                   |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
|                   |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
|                   |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
| **Qhov 2. Yog tus |   |         |     |    |   |          |          |   |
| menyuam koj ua    |   |         |     |    |   |          |          |   |
| ntawv thov rau    |   |         |     |    |   |          |          |   |
| tsis muaj vajtsev |   |         |     |    |   |          |          |   |
| nyob, nws         |   |         |     |    |   |          |          |   |
| tsevneeg ua zog   |   |         |     |    |   |          |          |   |
| ib sij tsim ib    |   |         |     |    |   |          |          |   |
| qho chaw rau ib   |   |         |     |    |   |          |          |   |
| qho lossis khiav  |   |         |     |    |   |          |          |   |
| tawm ntawm tsev   |   |         |     |    |   |          |          |   |
| ces kos tus cim   |   |         |     |    |   |          |          |   |
| rau lub tas ntawv |   |         |     |    |   |          |          |   |
| raws li hais      |   |         |     |    |   |          |          |   |
| thiab hu rau**    |   |         |     |    |   |          |          |   |
| **\[your school,  |   |         |     |    |   |          |          |   |
| homeless liaison, |   |         |     |    |   |          |          |   |
| migrant           |   |         |     |    |   |          |          |   |
| coordinator at    |   |         |     |    |   |          |          |   |
| phone #\]** Tsis  |   |         |     |    |   |          |          |   |
| muaj tsev nyob   |   |         |     |    |   |          |          |   |
| ib sij tsim chaw  |   |         |     |    |   |          |          |   |
| mus ntiav zog ua  |   |         |     |    |   |          |          |   |
|  khiav tawm      |   |         |     |    |   |          |          |   |
| ntawm tsev       |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
| **Qhov 3. Menyuam |   |         |     |    |   |          |          |   |
| Txais Los Tu**    |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
| Yog tus menyuam   |   |         |     |    |   |          |          |   |
| no yog welfare    |   |         |     |    |   |          |          |   |
| lossis lub tsev   |   |         |     |    |   |          |          |   |
| coj plaub ntug    |   |         |     |    |   |          |          |   |
| yog tus muaj cai  |   |         |     |    |   |          |          |   |
| kav xyuas, ces    |   |         |     |    |   |          |          |   |
| kos tus cim rau   |   |         |     |    |   |          |          |   |
| tas ntawv no     |   |         |     |    |   |          |          |   |
| thiab sau tus nqi |   |         |     |    |   |          |          |   |
| nyiaj niaj hli    |   |         |     |    |   |          |          |   |
| tau los siv rau   |   |         |     |    |   |          |          |   |
| tus menyuam no:   |   |         |     |    |   |          |          |   |
| \$                |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\_\_\_. |   |         |     |    |   |          |          |   |
| Hla mus ua qhov 5 |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
| **Qhov 4. Tag     |   |         |     |    |   |          |          |   |
| Nrho Qhov Nyiaj   |   |         |     |    |   |          |          |   |
| Tsev Neeg Ua Tau  |   |         |     |    |   |          |          |   |
| -- Koj yuav tsum  |   |         |     |    |   |          |          |   |
| qhia rau peb tias |   |         |     |    |   |          |          |   |
| tau pes tsawg     |   |         |     |    |   |          |          |   |
| thiab nquag tau   |   |         |     |    |   |          |          |   |
| tsawg zaus.**     |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
| **1. Lub Npe**    | * |         |     |    |   |          |          | * |
|                   | * |         |     |    |   |          |          | * |
| (Sau **txhua tus  | 2 |         |     |    |   |          |          | 3 |
| neeg** hauv lub   | . |         |     |    |   |          |          | . |
| tsev npe rau)     | Q |         |     |    |   |          |          | K |
|                   | h |         |     |    |   |          |          | o |
|                   | o |         |     |    |   |          |          | s |
|                   | v |         |     |    |   |          |          | t |
|                   | n |         |     |    |   |          |          | u |
|                   | y |         |     |    |   |          |          | s |
|                   | i |         |     |    |   |          |          | c |
|                   | a |         |     |    |   |          |          | i |
|                   | j |         |     |    |   |          |          | m |
|                   | t |         |     |    |   |          |          | r |
|                   | a |         |     |    |   |          |          | a |
|                   | u |         |     |    |   |          |          | u |
|                   | l |         |     |    |   |          |          | y |
|                   | o |         |     |    |   |          |          | o |
|                   | s |         |     |    |   |          |          | g |
|                   | t |         |     |    |   |          |          | T |
|                   | h |         |     |    |   |          |          | S |
|                   | i |         |     |    |   |          |          | I |
|                   | a |         |     |    |   |          |          | S |
|                   | b |         |     |    |   |          |          | t |
|                   | n |         |     |    |   |          |          | a |
|                   | q |         |     |    |   |          |          | u |
|                   | u |         |     |    |   |          |          | n |
|                   | a |         |     |    |   |          |          | y |
|                   | g |         |     |    |   |          |          | i |
|                   | t |         |     |    |   |          |          | a |
|                   | a |         |     |    |   |          |          | j |
|                   | u |         |     |    |   |          |          | d |
|                   | t |         |     |    |   |          |          | a |
|                   | s |         |     |    |   |          |          | b |
|                   | a |         |     |    |   |          |          | t |
|                   | w |         |     |    |   |          |          | s |
|                   | g |         |     |    |   |          |          | i |
|                   | z |         |     |    |   |          |          | l |
|                   | a |         |     |    |   |          |          | i |
|                   | u |         |     |    |   |          |          | * |
|                   | s |         |     |    |   |          |          | * |
|                   | * |         |     |    |   |          |          |   |
|                   | * |         |     |    |   |          |          |   |
|                   |   |         |     |    |   |          |          |   |
|                   | * |         |     |    |   |          |          |   |
|                   | P |         |     |    |   |          |          |   |
|                   | i |         |     |    |   |          |          |   |
|                   | v |         |     |    |   |          |          |   |
|                   | x |         |     |    |   |          |          |   |
|                   | a |         |     |    |   |          |          |   |
|                   | m |         |     |    |   |          |          |   |
|                   | l |         |     |    |   |          |          |   |
|                   | i |         |     |    |   |          |          |   |
|                   | : |         |     |    |   |          |          |   |
|                   | \ |         |     |    |   |          |          |   |
|                   | $ |         |     |    |   |          |          |   |
|                   | 1 |         |     |    |   |          |          |   |
|                   | 0 |         |     |    |   |          |          |   |
|                   | 0 |         |     |    |   |          |          |   |
|                   | / |         |     |    |   |          |          |   |
|                   | i |         |     |    |   |          |          |   |
|                   | b |         |     |    |   |          |          |   |
|                   | h |         |     |    |   |          |          |   |
|                   | l |         |     |    |   |          |          |   |
|                   | i |         |     |    |   |          |          |   |
|                   | s |         |     |    |   |          |          |   |
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|                   | b |         |     |    |   |          |          |   |
|                   | z |         |     |    |   |          |          |   |
|                   | a |         |     |    |   |          |          |   |
|                   | u |         |     |    |   |          |          |   |
|                   | g |         |     |    |   |          |          |   |
|                   | t |         |     |    |   |          |          |   |
|                   | a |         |     |    |   |          |          |   |
|                   | u |         |     |    |   |          |          |   |
|                   | j |         |     |    |   |          |          |   |
|                   | i |         |     |    |   |          |          |   |
|                   | b |         |     |    |   |          |          |   |
|                   | h |         |     |    |   |          |          |   |
|                   | l |         |     |    |   |          |          |   |
|                   | i |         |     |    |   |          |          |   |
|                   | s |         |     |    |   |          |          |   |
|                   | \ |         |     |    |   |          |          |   |
|                   | $ |         |     |    |   |          |          |   |
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|                   | 0 |         |     |    |   |          |          |   |
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|                   | s |         |     |    |   |          |          |   |
|                   | - |         |     |    |   |          |          |   |
|                   | t |         |     |    |   |          |          |   |
|                   | h |         |     |    |   |          |          |   |
|                   | i |         |     |    |   |          |          |   |
|                   | v |         |     |    |   |          |          |   |
|                   | t |         |     |    |   |          |          |   |
|                   | w |         |     |    |   |          |          |   |
|                   | g |         |     |    |   |          |          |   |
|                   | \ |         |     |    |   |          |          |   |
|                   | $ |         |     |    |   |          |          |   |
|                   | 1 |         |     |    |   |          |          |   |
|                   | 0 |         |     |    |   |          |          |   |
|                   | 0 |         |     |    |   |          |          |   |
|                   | / |         |     |    |   |          |          |   |
|                   | i |         |     |    |   |          |          |   |
|                   | b |         |     |    |   |          |          |   |
|                   | a |         |     |    |   |          |          |   |
|                   | s |         |     |    |   |          |          |   |
|                   | - |         |     |    |   |          |          |   |
|                   | t |         |     |    |   |          |          |   |
|                   | h |         |     |    |   |          |          |   |
|                   | i |         |     |    |   |          |          |   |
|                   | v |         |     |    |   |          |          |   |
|                   | * |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
|                   | N |         | We  |    | N |          | Tag Nrho |   |
|                   | y |         | lfa |    | y |          | Lwm yam  |   |
|                   | i |         | re, |    | i |          | Nyiaj    |   |
|                   | a |         | ny  |    | a |          | Tau Los  |   |
|                   | j |         | iaj |    | j |          |          |   |
|                   | u |         | pab |    | t |          |          |   |
|                   | a |         | yug |    | h |          |          |   |
|                   | z |         | tus |    | e |          |          |   |
|                   | o |         | me  |    | m |          |          |   |
|                   | g |         | nyu |    | t |          |          |   |
|                   | t |         | am, |    | u |          |          |   |
|                   | a |         | ny  |    | a |          |          |   |
|                   | u |         | iaj |    | j |          |          |   |
|                   | u |         | tej |    | r |          |          |   |
|                   | a |         | ni  |    | a |          |          |   |
|                   | n |         | amt |    | u |          |          |   |
|                   | t |         | xiv |    | t |          |          |   |
|                   | e |         | sib |    | u |          |          |   |
|                   | j |         | nr  |    | s |          |          |   |
|                   | y |         | auj |    | n |          |          |   |
|                   | u |         | es  |    | e |          |          |   |
|                   | a |         | ib  |    | e |          |          |   |
|                   | v |         | tug |    | g |          |          |   |
|                   | r |         | t   |    | s |          |          |   |
|                   | a |         | hem |    | o |          |          |   |
|                   | u |         | yug |    | l |          |          |   |
|                   | g |         | ib  |    | o |          |          |   |
|                   | t |         | tug |    | s |          |          |   |
|                   | x |         |     |    | s |          |          |   |
|                   | i |         |     |    | i |          |          |   |
|                   | a |         |     |    | s |          |          |   |
|                   | v |         |     |    | m |          |          |   |
|                   | t |         |     |    | u |          |          |   |
|                   | a |         |     |    | a |          |          |   |
|                   | w |         |     |    | j |          |          |   |
|                   | m |         |     |    | m |          |          |   |
|                   |   |         |     |    | o |          |          |   |
|                   |   |         |     |    | b |          |          |   |
|                   |   |         |     |    | u |          |          |   |
|                   |   |         |     |    | a |          |          |   |
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|                   |   |         |     |    | t |          |          |   |
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|                   |   |         |     |    | h |          |          |   |
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|                   |   |         |     |    | , |          |          |   |
|                   |   |         |     |    | n |          |          |   |
|                   |   |         |     |    | y |          |          |   |
|                   |   |         |     |    | i |          |          |   |
|                   |   |         |     |    | a |          |          |   |
|                   |   |         |     |    | j |          |          |   |
|                   |   |         |     |    | l |          |          |   |
|                   |   |         |     |    | a |          |          |   |
|                   |   |         |     |    | u |          |          |   |
|                   |   |         |     |    | s |          |          |   |
|                   |   |         |     |    | , |          |          |   |
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|                   |   |         |     |    | a |          |          |   |
|                   |   |         |     |    | u |          |          |   |
|                   |   |         |     |    | s |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
| *(Pivxamli)\      | \ |         | \$[ |    | [ |          | \$\_\_\  | - |
| Jane Smith*       | $ |         | 150 |    | \ |          | _\_\_\_/ |   |
|                   | [ |         | /ib |    | $ |          | \_\_\_\_ |   |
|                   | 2 |         | as- |    | 1 |          | \_\_\_\_ |   |
|                   | 0 |         | thi |    | 0 |          |          |   |
|                   | 0 |         | v]{ |    | 0 |          |          |   |
|                   | / |         | .un |    | / |          |          |   |
|                   | i |         | der |    | i |          |          |   |
|                   | b |         | lin |    | b |          |          |   |
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|                   | s |         | _\_ |    | l |          |          |   |
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|                   | h |         |     |    | ] |          |          |   |
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|                   | v |         |     |    | . |          |          |   |
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+-------------------+---+---------+-----+----+---+----------+----------+---+
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+-------------------+---+---------+-----+----+---+----------+----------+---+
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+-------------------+---+---------+-----+----+---+----------+----------+---+
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+-------------------+---+---------+-----+----+---+----------+----------+---+
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|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
|                   | \ |         | \   |    | \ |          | \$\_\    | - |
|                   | $ |         | $\_ |    | $ |          | _\_\_\_\ |   |
|                   | \ |         | \_\ |    | \ |          | _/\_\_\_ |   |
|                   | _ |         | _\_ |    | _ |          | \_\_\_\_ |   |
|                   | \ |         | \_\ |    | \ |          |          |   |
|                   | _ |         | _/\ |    | _ |          |          |   |
|                   | \ |         | _\_ |    | \ |          |          |   |
|                   | _ |         | \_\ |    | _ |          |          |   |
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|                   | \ |         | _\_ |    | \ |          |          |   |
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|                   | _ |         |     |    | _ |          |          |   |
|                   | / |         |     |    | / |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
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|                   | _ |         |     |    | _ |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
|                   | \ |         | \   |    | \ |          | \$\_\    | - |
|                   | $ |         | $\_ |    | $ |          | _\_\_\_\ |   |
|                   | \ |         | \_\ |    | \ |          | _/\_\_\_ |   |
|                   | _ |         | _\_ |    | _ |          | \_\_\_\_ |   |
|                   | \ |         | \_\ |    | \ |          |          |   |
|                   | _ |         | _/\ |    | _ |          |          |   |
|                   | \ |         | _\_ |    | \ |          |          |   |
|                   | _ |         | \_\ |    | _ |          |          |   |
|                   | \ |         | _\_ |    | \ |          |          |   |
|                   | _ |         | \_\ |    | _ |          |          |   |
|                   | \ |         | _\_ |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | / |         |     |    | / |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
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|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
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|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
|                   | \ |         | \   |    | \ |          | \$\_\    | - |
|                   | $ |         | $\_ |    | $ |          | _\_\_\_\ |   |
|                   | \ |         | \_\ |    | \ |          | _/\_\_\_ |   |
|                   | _ |         | _\_ |    | _ |          | \_\_\_\_ |   |
|                   | \ |         | \_\ |    | \ |          |          |   |
|                   | _ |         | _/\ |    | _ |          |          |   |
|                   | \ |         | _\_ |    | \ |          |          |   |
|                   | _ |         | \_\ |    | _ |          |          |   |
|                   | \ |         | _\_ |    | \ |          |          |   |
|                   | _ |         | \_\ |    | _ |          |          |   |
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|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | / |         |     |    | / |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
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|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
|                   | \ |         | \   |    | \ |          | \$\_\    | - |
|                   | $ |         | $\_ |    | $ |          | _\_\_\_\ |   |
|                   | \ |         | \_\ |    | \ |          | _/\_\_\_ |   |
|                   | _ |         | _\_ |    | _ |          | \_\_\_\_ |   |
|                   | \ |         | \_\ |    | \ |          |          |   |
|                   | _ |         | _/\ |    | _ |          |          |   |
|                   | \ |         | _\_ |    | \ |          |          |   |
|                   | _ |         | \_\ |    | _ |          |          |   |
|                   | \ |         | _\_ |    | \ |          |          |   |
|                   | _ |         | \_\ |    | _ |          |          |   |
|                   | \ |         | _\_ |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | / |         |     |    | / |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
|                   | \ |         |     |    | \ |          |          |   |
|                   | _ |         |     |    | _ |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
| **Qhov 5. Xee npe |   |         |     |    |   |          |          |   |
| thiab Xaus-Sau    |   |         |     |    |   |          |          |   |
| Nabnpawb (Cov     |   |         |     |    |   |          |          |   |
| muaj hnub nyoog   |   |         |     |    |   |          |          |   |
| yuav tsum xee     |   |         |     |    |   |          |          |   |
| npe)**            |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
| Tus muaj hnub     |   |         |     |    |   |          |          |   |
| nyoog hauv        |   |         |     |    |   |          |          |   |
| tsevneeg yuav     |   |         |     |    |   |          |          |   |
| tsum xee npe rau  |   |         |     |    |   |          |          |   |
| tsab ntawv teev   |   |         |     |    |   |          |          |   |
| npe no. Yog Qhov  |   |         |     |    |   |          |          |   |
| 4 raug ua tiav,   |   |         |     |    |   |          |          |   |
| mas tus muaj hnub |   |         |     |    |   |          |          |   |
| nyoog uas xee npe |   |         |     |    |   |          |          |   |
| rau tsab ntawv no |   |         |     |    |   |          |          |   |
| yuav tsum sau nws |   |         |     |    |   |          |          |   |
| tus Xaus-Saus     |   |         |     |    |   |          |          |   |
| Nabnpawb rau      |   |         |     |    |   |          |          |   |
| lossis kos tus    |   |         |     |    |   |          |          |   |
| cim rau tas ntawv |   |         |     |    |   |          |          |   |
| tias "Kuv tsis    |   |         |     |    |   |          |          |   |
| muaj Xaus-Saus    |   |         |     |    |   |          |          |   |
| Nabnpawb." (xyuas |   |         |     |    |   |          |          |   |
| Cov Lus Txog Txoj |   |         |     |    |   |          |          |   |
| Cai Npog Cia Tsis |   |         |     |    |   |          |          |   |
| Pub Paub nyob     |   |         |     |    |   |          |          |   |
| nram qab ntawm    |   |         |     |    |   |          |          |   |
| nplooj ntawv      |   |         |     |    |   |          |          |   |
| no.)\             |   |         |     |    |   |          |          |   |
| *Kuv lav paub     |   |         |     |    |   |          |          |   |
| (cog lus) tias    |   |         |     |    |   |          |          |   |
| cov lus nyob rau  |   |         |     |    |   |          |          |   |
| hauv tsab ntawv   |   |         |     |    |   |          |          |   |
| teev npe no mas   |   |         |     |    |   |          |          |   |
| yog lus tseeb     |   |         |     |    |   |          |          |   |
| thiab tej         |   |         |     |    |   |          |          |   |
| nyiajtxiag tau    |   |         |     |    |   |          |          |   |
| los yeej raug     |   |         |     |    |   |          |          |   |
| muab qhia tag.    |   |         |     |    |   |          |          |   |
| Kuv tau taub tias |   |         |     |    |   |          |          |   |
| cov lus kuv muab  |   |         |     |    |   |          |          |   |
| no yuav pab tsev  |   |         |     |    |   |          |          |   |
| kawmntawv tau     |   |         |     |    |   |          |          |   |
| txais nyiaj pab   |   |         |     |    |   |          |          |   |
| tuaj ntawm        |   |         |     |    |   |          |          |   |
| Tseemfwv tebchaws |   |         |     |    |   |          |          |   |
| tuaj. Kuv tau     |   |         |     |    |   |          |          |   |
| taub tias cov     |   |         |     |    |   |          |          |   |
| neeg ua haujlwm   |   |         |     |    |   |          |          |   |
| rau tsev          |   |         |     |    |   |          |          |   |
| kawmntawv tejzaum |   |         |     |    |   |          |          |   |
| kuj yuav taug     |   |         |     |    |   |          |          |   |
| xyuas (tshawb     |   |         |     |    |   |          |          |   |
| xyuas) txog cov   |   |         |     |    |   |          |          |   |
| lus no. Kuv tau   |   |         |     |    |   |          |          |   |
| taub tias yog kuv |   |         |     |    |   |          |          |   |
| txhob txwm dag,   |   |         |     |    |   |          |          |   |
| mas tejzaum yuav  |   |         |     |    |   |          |          |   |
| ua rau kuv cov    |   |         |     |    |   |          |          |   |
| menyuam tsis tau  |   |         |     |    |   |          |          |   |
| txais kev pab rau |   |         |     |    |   |          |          |   |
| tej mov noj thiab |   |         |     |    |   |          |          |   |
| tejzaum kuv yuav  |   |         |     |    |   |          |          |   |
| raug foob.*       |   |         |     |    |   |          |          |   |
|                   |   |         |     |    |   |          |          |   |
| Xee npe nov:      |   |         |     |    |   |          |          |   |
| X\_\_\_\_\        |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\_\_\_\ |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
| Sau               |   |         |     |    |   |          |          |   |
| Npe               |   |         |     |    |   |          |          |   |
| :\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\_\_\_\ |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
| Hnub tim:         |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\       |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
|                   |   |         |     |    |   |          |          |   |
| Chaw              |   |         |     |    |   |          |          |   |
| nyob:             |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\_\_\_\ |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\_\_\_\ |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\_\_\_\ |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
| Xovtooj           |   |         |     |    |   |          |          |   |
| Na                |   |         |     |    |   |          |          |   |
| bnpawb:\_\_\_\_\_ |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\_\_\_\ |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
|                   |   |         |     |    |   |          |          |   |
| Xaus-Sau          |   |         |     |    |   |          |          |   |
| Nabnpawb: \_\_    |   |         |     |    |   |          |          |   |
| \_\_ \_\_ - \_\_  |   |         |     |    |   |          |          |   |
| \_\_ - \_\_ \_\_  |   |         |     |    |   |          |          |   |
| \_\_ \_\_  Kuv   |   |         |     |    |   |          |          |   |
| tsis muaj         |   |         |     |    |   |          |          |   |
| Xaus-Saus         |   |         |     |    |   |          |          |   |
| Nabnpawb          |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
| **Qhov 6. Txog    |   |         |     |    |   |          |          |   |
| menyuam tawv      |   |         |     |    |   |          |          |   |
| nqaij thiab haiv  |   |         |     |    |   |          |          |   |
| neeg (tsis teb    |   |         |     |    |   |          |          |   |
| los tsis ua       |   |         |     |    |   |          |          |   |
| cas)**            |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
| [Kos ib tug cim   |   |         |     |    |   |          |          |   |
| lossis tshaj rau  |   |         |     |    |   |          |          |   |
| tawv              |   |         |     |    |   |          |          |   |
| nq                |   |         |     |    |   |          |          |   |
| aij]{.underline}: |   |         |     |    |   |          |          |   |
| [Kos ib tug cim   |   |         |     |    |   |          |          |   |
| rau haiv          |   |         |     |    |   |          |          |   |
| n                 |   |         |     |    |   |          |          |   |
| eeg]{.underline}: |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
| -   Esxias  Khab |   |         |     |    |   |          |          |   |
|     Asmeslivkas   |   |         |     |    |   |          |          |   |
|     lossis Khab   |   |         |     |    |   |          |          |   |
|     Alaskas      |   |         |     |    |   |          |          |   |
|     Xaspasniv     |   |         |     |    |   |          |          |   |
|     lossis Latino |   |         |     |    |   |          |          |   |
|                   |   |         |     |    |   |          |          |   |
| -   Dawb  Neeg   |   |         |     |    |   |          |          |   |
|     Hawaii lossis |   |         |     |    |   |          |          |   |
|     Neeg Nroog    |   |         |     |    |   |          |          |   |
|     Hiavtxwv      |   |         |     |    |   |          |          |   |
|     Pacific      |   |         |     |    |   |          |          |   |
|     Tsis Yog      |   |         |     |    |   |          |          |   |
|     Xaspasniv     |   |         |     |    |   |          |          |   |
|     lossis Latino |   |         |     |    |   |          |          |   |
|                   |   |         |     |    |   |          |          |   |
|  Dub lossis      |   |         |     |    |   |          |          |   |
| African           |   |         |     |    |   |          |          |   |
| Asmeslivkas  Lwm |   |         |     |    |   |          |          |   |
| Yam               |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
| **Txhob teb cov   |   |         |     |    |   |          |          |   |
| lus ntawm qhov    |   |         |     |    |   |          |          |   |
| nov. Nov yog rau  |   |         |     |    |   |          |          |   |
| tsev kawmntawv    |   |         |     |    |   |          |          |   |
| siv xwb.**        |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+
| Annual Income     |   |         |     |    |   |          |          |   |
| Conversion:       |   |         |     |    |   |          |          |   |
| Weekly x 52,      |   |         |     |    |   |          |          |   |
| Every 2 Weeks x   |   |         |     |    |   |          |          |   |
| 26, Twice A Month |   |         |     |    |   |          |          |   |
| x 24 Monthly x 12 |   |         |     |    |   |          |          |   |
|                   |   |         |     |    |   |          |          |   |
| Total Income:     |   |         |     |    |   |          |          |   |
| \_\_\_\           |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
| Per:  Week,     |   |         |     |    |   |          |          |   |
| Every 2 Weeks,   |   |         |     |    |   |          |          |   |
| Twice A Month,   |   |         |     |    |   |          |          |   |
| Month,  Year     |   |         |     |    |   |          |          |   |
| Household size:   |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\_\_\_  |   |         |     |    |   |          |          |   |
|                   |   |         |     |    |   |          |          |   |
| Categorical       |   |         |     |    |   |          |          |   |
| Eligibility:      |   |         |     |    |   |          |          |   |
| \_\_\_ Date       |   |         |     |    |   |          |          |   |
| Withdrawn:        |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\       |   |         |     |    |   |          |          |   |
| _\_\_Eligibility: |   |         |     |    |   |          |          |   |
| Free\_\_\_        |   |         |     |    |   |          |          |   |
| Reduced\_\_\_     |   |         |     |    |   |          |          |   |
| Denied\_\_\_      |   |         |     |    |   |          |          |   |
| Reason:           |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\_      |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\_\_\_\ |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
|                   |   |         |     |    |   |          |          |   |
| Temporary:        |   |         |     |    |   |          |          |   |
| Free\_\_\_\_\_    |   |         |     |    |   |          |          |   |
| Reduced\_\_\_\_\_ |   |         |     |    |   |          |          |   |
| Time Period:      |   |         |     |    |   |          |          |   |
| \_\_\             |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
| (expires after    |   |         |     |    |   |          |          |   |
| \_\_\_\_\_ days)  |   |         |     |    |   |          |          |   |
|                   |   |         |     |    |   |          |          |   |
| Determining       |   |         |     |    |   |          |          |   |
| Official's        |   |         |     |    |   |          |          |   |
| Signature:        |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\       |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\_\_\_\ |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\_\_\_\ |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
| Date:             |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\       |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
|                   |   |         |     |    |   |          |          |   |
| Confirming        |   |         |     |    |   |          |          |   |
| Official's        |   |         |     |    |   |          |          |   |
| Signature:        |   |         |     |    |   |          |          |   |
| \_                |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\_\_\_\ |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
| Date:             |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\_\_    |   |         |     |    |   |          |          |   |
| Follow-up         |   |         |     |    |   |          |          |   |
| Official's        |   |         |     |    |   |          |          |   |
| Signature:        |   |         |     |    |   |          |          |   |
| \_                |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\_\_\_\ |   |         |     |    |   |          |          |   |
| _\_\_\_\_\_\_\_\_ |   |         |     |    |   |          |          |   |
| Date:             |   |         |     |    |   |          |          |   |
| \_\_\_\_\_\_      |   |         |     |    |   |          |          |   |
+-------------------+---+---------+-----+----+---+----------+----------+---+

**Koj tus menyuam tejzaum muaj cuabkav tau txais mov noj dawb lossis luv
nqi mov yog koj tsevneeg qhov nyiaj tau los ntawd poob ncaj raws li tus
nqi phua tseg nyob hauv lub roojntawv no.**

**Cov Lus Txog Txoj Cai Npog Cia Tsis Pub Paub: Nov piav qhia tias peb
yuav siv cov lus koj muab li cas.** Txoj cai Richard B. Russell National
School Lunch Act yuav tseem kom cov lus no mas yuav tsum qhia rau hauv
tsab ntawv teev npe no. Cov lus no, koj tsis tas qhia los tsis ua cas,
tiamsis yog tsis qhia, mas peb tsis muaj cuab kav yuav pomzoo pub koj
tus menyuam tau txais mov noj dawb lossis luv nqi mov. Koj yuav tsum
qhia tus xaus-saus nabnpawb ntawm tus laus muaj hnub nyoog ntawm
tsevneeg uas xee tsab ntawv thov no rau. Tsis tas muab tus xaus-saus yog
ua thov rau tus menyuam txais los tu lossis yog koj qhia tias tau txais
Food Stamp Program, Program Pab Rau Tsevneeg Txom Nyem (TANF) lossis yog
muaj tus case nabnpawb qhia tias tau txais Zaub Mov Faib Pub Noj Hauv
Khab Zos (FDPIR), lossis lwm hom kev pab FDPIR uas muaj tus nabnpawb rau
koj tus menyuam lossis yog koj qhia tias tus laus muaj hnub nyoog hauv
tsevneeg uas xee tsab ntawv thov thab niam muaj xaus-saus nabnpawb. Peb
yuav siv cov lus muab tuaj txiav txim xyuas saib koj tus menyuam puas
muaj cuabkav tau txais mov noj dawb lossis luv nqi mov, thiab khiav tej
haujlwm tswjfwm xyuas txog tej kev pab txog noj su thiab noj tshais.
TEJZAUM peb kuj muab cov ntaubntawv qhia txog kam tau txais mov noj
ntawd pub rau tej programs txog kev kawmntawv, kev noj qab nyob huv,
thiab kev noj haus kom pab lawv ntsuas xyuas, muab nyiaj pab, lossis
txiav txim saib yuav muaj dab tsi zoo pab rau lawv cov programs, pub rau
cov neeg kuaj xyuas cov programs, thiab cov cob-nab-thib tswjfwm xyuas
txog tej haujlwm no xyuas saib puas muaj leejtwg ua txhaum tej kev cai.

**Lus Txog Tsis Pub Txhob Txwm Xyeej Tsis Nyiam: Nov qhia txog tias yog
koj xav tias luag ua tsis ncaj rau koj mas koj yuav tsum ua li cas**.
Raws li Tseemfwv tebchaws txoj cai thiab txoj cai nyob rau U.S.
Department of Agiculture, mas qhov chaw no tsis pub xwb tim lim hiam
xyeej tsis kam vim nqaij tawv, xim nqaij, lub tebchaws tus neeg tuaj,
pojniam lossis txivneej, hnub nyoog, lossis muaj mob xiam oob khab. Yog
yuav ua ntaubntawv foob tias luag txhob txwm lim hiam xyeej tsis kam,
mas yuav tsum sau mus rau *USDA, Director, Office of Civil Rights, 1400
Independence Avenue, SW, Washington DC 20250-9410* lossis hu rau
800-795-3272 lossis 202-720-6382 (TTY). USDA yog ib qhov chaw pab thiab
chaw ntiav neeg ncaj ncees rau sawvdaws.

**QHIA COV LUS PUB RAU MEDICAID/SCHIP**

Txog Niam thiab Txiv/Tus Saib Xyuas:

Yog koj cov menyuam tau txais mov noj dawb lossis luv nqi mov tom tsev
kawmntawv, mas tejzaum lawv kuj muaj cuabkav tau txais ntauntawv kho mob
dawb lossis ntaubntawv luv nqi kho mob ntawm Medicaid lossis ntawm State
Children's Health Insurance Program (SCHIP). Cov menyuam muaj ntaubntawv
kho mob mas ntxim yuav tau txais kev saib xyuas kom noj qab nyob huv dua
thiab yuav tsis khaj ntawv heev vim pheej muaj mob.

Vim tias ntaubntawv kho mob tseemceeb heev rau menyuam tej kev noj qab
nyob huv, **txoj cai tso kev rau peb qhia rau Medicaid thiab SCHIP tias
koj cov menyuam tau txais mov noj dawb lossis luv nqi mov**, ***tsuas
ntshai koj ho hais rau peb tias kom txhob muab***. Medicaid thiab SCHIP
tsuas siv cov ntaubntawv xyuas saib cov menyuam twg thiaj ntxim yuav tau
txais kev pab ntawm lawv cov programs. Cov tub teg ua haujlwm nyob rau
ntawm tus program ntawd tejzaum kuj yuav hu rau koj kom koj ua
ntaubntawv muab koj cov menyuam ua npe thov (Tsab ntawv teev npe thov
Mov Noj Dawb thiab Luv Nqi Mov Tom Tsev Kawmntawv tsis yog tsab uas cia
li muab koj cov menyuam tso thov ntaubntawv ees-xus-lees kho mob).

Yog koj tsis xav kom peb muab koj cov lus qhia pub rau Medicaid lossis
SCHIP, mas koj yuav tsum teb cov lus ntawm tsab ntawv hauv qab no thiab
muab xa tuaj (txawm koj xa tsab ntawv no tuaj los yeej tsis ua teebmeem
dab tsi rau qhov koj tus menyuam yuav tau txais thiab tsis tau txais mov
noj dawb lossis luv nqi mov).

-   **Tsis Kam! KUV TSIS KAM** muab cov lus ntawm Tsab Ntawv Teev Npe
    Thov Mov Noj Dawb thiab Luv Nqi Mov Tom Tsev Kawmntawv qhia rau
    Medicaid lossis State Children's Health Insurance Program.

**Yog koj kos cim rau tias tsis kam, ces teb cov lus hauv qab no.**

Tus Menyuam Lub Npe: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Tsev
Kawmntawv:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Tus Menyuam Lub Npe: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Tsev
Kawmntawv:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Tus Menyuam Lub Npe: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Tsev
Kawmntawv:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Tus Menyuam Lub Npe: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Tsev
Kawmntawv:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Niam thiab Txiv/Tus Saib Xyuas Tus Lais Xees:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Hnub tim: \_\_\_\_\_\_\_\_\_\_\_\_

Sau Lub Npe: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Chaw Nyob:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Xav paub dab tsi ntxiv, mas koj hu rau **\[ name\]** ntawm **\[
phone\].**

**Xa tsab ntawv no rau: \[ address\] tsis pub dhau \[date\].**

**QHIA COV LUS PUB RAU TEJ PROGRAMS LWMYAM**

Txog Niam thiab Txiv/Tus Saib Xyuas:

Vim tsis xam kom laug koj lub dag lub zog thiab sijhawm, mas tejzaum cov
lus koj muab rau peb txog koj Tsab Ntawv Teev Npe Thov Mov Noj Dawb
thiab Luv Nqi Mov Tom Tsev Kawmntawv yuav raug muab qhia pub rau lwm cov
programs uas tejzaum koj cov menyuam muaj cuabkav tau txais. **Rau cov
program hauv qab no mas peb yuav tsum tau lus tso cai ntawm koj mas peb
thiaj muab qhia tau. Txawm koj xa tsab ntawv no tuaj los yeej tsis ua
teebmeem dab tsi rau qhov koj tus menyuam yuav tau txais thiab tsis tau
txais mov noj dawb lossis luv nqi mov.**

-   **Tsis Kam! KUV TSIS KAM** muab cov lus ntawm Tsab Ntawv Teev Npe
    Thov Mov Noj Dawb thiab Luv Nqi Mov Tom Tsev Kawmntawv qhia rau cov
    program no.

-   **Kam! KUV KAM** kom cov tub teg ua haujlwm hauv tsev kawmntawv muab
    cov lus ntawm Tsab Ntawv Teev Npe Thov Mov Noj Dawb thiab Luv Nqi
    Mov Tom Tsev Kawmntawv qhia rau **\[ name of program specific to
    your school\]**.

-   **Kam! KUV KAM** kom cov tub teg ua haujlwm hauv tsev kawmntawv muab
    cov lus ntawm Tsab Ntawv Teev Npe Thov Mov Noj Dawb thiab Luv Nqi
    Mov Tom Tsev Kawmntawv qhia rau **\[ name of program specific to
    your school\]**.

-   **Kam! KUV KAM** kom cov tub teg ua haujlwm hauv tsev kawmntawv muab
    cov lus ntawm Tsab Ntawv Teev Npe Thov Mov Noj Dawb thiab Luv Nqi
    Mov Tom Tsev Kawmntawv qhia rau **\[ name of program specific to
    your school\]**.

**Yog koj kos tus cim rau kam rau tas twg ntawm cov tas saum toj no, mas
koj yuav tsum teb cov lus hauv qab no. Koj cov ntaubntawv yuav raug muab
qhia pub rau cov programs koj kos tus cim rau.**

Tus Menyuam Lub Npe: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Tsev
Kawmntawv:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Tus Menyuam Lub Npe: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Tsev
Kawmntawv:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Tus Menyuam Lub Npe: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Tsev
Kawmntawv:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Tus Menyuam Lub Npe: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Tsev
Kawmntawv:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Niam thiab Txiv/Tus Saib Xyuas Tus Lais Xees:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Hnub tim: \_\_\_\_\_\_\_\_\_\_\_\_

Sau Lub Npe:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chaw Nyob:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Xav paub dab tsi ntxiv, mas koj hu rau **\[ name\]** ntawm **\[
phone\].**

**Xa tsab ntawv no rau:** **\[ address**\] **tsis pub dhau**
**\[date\].**

**PEB YUAV TSUM KUAJ XYUAS KOJ TSAB NTAWV TEEV NPE**

**Koj yuav tsum xa cov ntaubntawv peb toob kam, lossis hu rau \[name\]
tsis pub dhau \[date\], tsis li mas koj tus menyuam yuav tsis tau txais
mov noj dawb lossis luv nqi mov.**

Tsev Kawmntawv:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Hnub tim: \_\_\_\_\_\_\_\_\_\_\_

Txog \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_:

Peb tabtom kuaj xyuas koj Tsab Ntawv Teev Npe Thov Mov Noj Dawb thiab
Luv Nqi Mov Tom Tsev Kawmntawv. Tseemfwv tebchaws cov cai yuav tseem kom
peb ua zaj no kom paub tseeb tias tsuas kam cov muaj cuab kav tau txais
xwb thiaj li tau mov noj dawb thiab luv nqi mov. Koj yuav tsum xa cov
ntaubntawv tuaj ua povthawj tias **\[names of children\]** yeej muaj
cuab kav tau txais. Yog ua tau, xav kom xa cov qauv luam tawm tuaj, tsis
yog cov qauv tseem tseem. Yog koj xa cov qauv tseem tseem tuaj, mas yog
tsis hnov koj hais kom peb xa rov qab mas peb yuav tsis xa.

**1. Yog koj tau txais Food Stamps lossis TANF thaum koj ua ntawv teev
npe thov mov noj dawb lossis luv nqi mov, lossis sijhawm twg ua qab
ntawd, mas koj yuav tsum xa ib daim qauv luam tawm ntawm cov no tuaj rau
peb.**

-   Food Stamp lossis daim ntawv TANF Certification Notice uas muaj hnub
    vas-thib lees paub.

-   Daim ntawv tuaj ntawm Food Stamp lossis loo-kam Welfare Office uas
    qhia tias koj tau txais Food Stamps lossis TANF.

-   **Txhob xa koj daim npav EBT.**

**2. Yog koj tau txais tsab ntawv no rau tus menyuam tsis muaj tsev
nyob, tus menyuam ib sij tsiv chaw ua haujlwm ib qho rau ib qho lossis
tus menyuam khiav tawm ntawm tsev, mas koj yuav tsum hu rau \[school,
homeless liaison, or migrant coordinator\] kom pab.**

**3. Yog tus menyuam yog tus txais los tu:**

Xa tej ntaub ntawv tom qhov chaw txais tos tus menyuam tuaj rau peb.

**4. Yog koj tsis tau txais Food Stamps lossis TANF rau koj cov menyuam
mas:**

A.  Sau lub npe thiab tus xaus-saus nabnpawb rau txhua tus laus muaj
    hnub nyoog ntawm tsevneeg rau hauv qab no.

+----------------------------+--------------------------------+--------+
| Lub Npe                    | Tus Xaus-Saus Nabnpawb         | Tsis   |
|                            |                                | Muaj   |
|                            | (xyuas Cov Lus Txog Txoj Cai   | Xau    |
|                            | Npog Cia Tsis Pub Paub, nplooj | s-Saus |
|                            | ntawv 2**)**                   |        |
+----------------------------+--------------------------------+--------+
| \_\_\_\_\_\_\_\_\_\_\_     | \_\_ \_\_ \_\_ - \_\_ \_\_ -   | -      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_ \_\_ \_\_ \_\_            |        |
+----------------------------+--------------------------------+--------+
| \_\_\_\_\_\_\_\_\_\_\_     | \_\_ \_\_ \_\_ - \_\_ \_\_ -   | -      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_ \_\_ \_\_ \_\_            |        |
+----------------------------+--------------------------------+--------+
| \_\_\_\_\_\_\_\_\_\_\_     | \_\_ \_\_ \_\_ - \_\_ \_\_ -   | -      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_ \_\_ \_\_ \_\_            |        |
+----------------------------+--------------------------------+--------+
| \_\_\_\_\_\_\_\_\_\_\_     | \_\_ \_\_ \_\_ - \_\_ \_\_ -   | -      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_ \_\_ \_\_ \_\_            |        |
+----------------------------+--------------------------------+--------+
| \_\_\_\_\_\_\_\_\_\_\_     | \_\_ \_\_ \_\_ - \_\_ \_\_ -   | -      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_ \_\_ \_\_ \_\_            |        |
+----------------------------+--------------------------------+--------+
| \_\_\_\_\_\_\_\_\_\_\_     | \_\_ \_\_ \_\_ - \_\_ \_\_ -   | -      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_ \_\_ \_\_ \_\_            |        |
+----------------------------+--------------------------------+--------+
| \_\_\_\_\_\_\_\_\_\_\_     | \_\_ \_\_ \_\_ - \_\_ \_\_ -   | -      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_ \_\_ \_\_ \_\_            |        |
+----------------------------+--------------------------------+--------+
| \_\_\_\_\_\_\_\_\_\_\_     | \_\_ \_\_ \_\_ - \_\_ \_\_ -   | -      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_ \_\_ \_\_ \_\_            |        |
+----------------------------+--------------------------------+--------+

B.  Xa nplooj ntawv no ua ke nrog cov ntaubntawv qhia tias koj tsev neeg
    tau txais nyiaj pes tsawg ntawm qhov chaw twg los tuaj rau peb.

Cov ntaubntawv koj xa tuaj yuav tsum muaj tus neeg uas tau txais qhov
nyiaj ntawd **lub npe**, **hnub vas thib** tau txais, **tau txais pes
tsawg**, thiab **nquag tau txais tsawg zaus**. **Xa cov ntaubntawv rau:
\[address\].**

**[Cov ntaubntawv siv tau mas yog:]{.underline}**

**Haujlwm:** Tw tshev lossis lub hnab ntawv them nyiaj uas qhia tias
nquag tau txais qhov nyiaj tsawg zaus; daim ntawv tuaj ntawm tus tswv
ntiav zog tuaj qhia tias nqi zog yog pes tsawg, thiab nquag them rau
lawv li cas; lossis tej ntaubntawv ntawm tej lagluam lossis ntawm kev ua
teb, xws li cov ntaubntawv sau txog cov nyiaj ua lagluam lossis phau
ntawv txog cov se.

**Nyiaj Xaus-Saus, Nyiaj Them Rau Neeg So Haujlwm los Xiam-Oob-Khab,
lossis Nyiaj Laus**: Daim ntawv luag qhia tias pab nyiaj laus, daim
ntawv qhia tias pab dab tsi, lossis tsab ntawv ceebtoom tias yuav pab
nyiaj los so lossis xiam-oob-khab li cas.

**Nyiaj Pab Thaum Poob Haujlwm, Muaj Mob, lossis Nyiaj Them Rau Neeg Ua
Haujlwm Raug Mob:** Tsab ntawv tuaj ntawm lub Xeev qhia rau koj tias koj
tau txais nyiaj poob haujlwm, tw tshev, lossis tsab ntawv tuaj ntawm
qhov chaw xa nyiaj tuaj pab rau tus ua haujlwm raug mob.

**Nyiaj Welfare them tuaj**: Daim ntawv tuaj ntawm loo-kam welfare tuaj
qhia tias yuav tau txais dab tsi pab.

**Nyiaj Them Yug Cov Menyuam thiab Rau Tus Niam lossis Tus Txiv Vim Sib
Nrauj:** Tsab ntawv tswv xam phua kom them, tsab ntawv cog lus pomzoo,
lossis cov qauv tw tshev uas tau txais.

**Lwm Yam Nyiaj Tau Los (xws li nyiaj xoj tsev rau luag nyob):** Cov
ntaubntawv qhia txog qhov nyiaj tau txais, nquag tau txais tsawg zaus,
thiab hnub vas thib tau txais.

**Tsis Tau Nyiaj Dab Tsi Li:** Sau ib nyuag ntawv piav qhia txog tias
koj xyuas zaubmov, khaub-ncaws thiab tsev nyob li cas rau koj tsev neeg,
thiab thaum twg koj thiaj yuav muaj nyiaj nkag los**.**

**Tus Program Pab Nyiaj Them Chaw Nyob Rau Tub Rog:** Tsab ntawv lossis
daim ntawv cog lus qhia tias koj tej chaw nyob mas yog them los ntawm
tus Program Pab Nyiaj Them Chaw Nyob Rau Cov Tub Rog.

**Thajtsam Sijhawm Uas Tseem Kam Txais Cov Ntaubntawv Qhia Txog Cov
Nyiaj Tau Los:** Thov xa cov ntaubntawv uas qhia txog cov nyiaj tau los
thaum sijhawm koj ua ntaubntawv thov pab. Yog koj tsis muaj cov
ntaubntawv no, mas koj muaj cuab kav xa tej ntaubntawv tuaj zujzus pib
thaum koj ua ntawv thov txog ntua thaum luag kuaj xyuas cov ntaubntawv.

Yog koj muaj lus xav nug lossis toobkam pab, mas thov hu rau
**\[name\]** ntawm **\[phone number\]**. Qhov hu no hu dawg. **\[Toll
free or reverse charge explanation\].**

Ua Tsaug,

**\[signature\]**

Cov Lus Txog Txoj Cai Npog Cia Tsis Pub Paub: Txoj cai Richard B.
Russell National School Lunch Act yuav tseem kom cov lus no mas yuav
tsum qhia rau hauv tsab ntawv teev npe no. Cov lus no, koj tsis tas qhia
los tsis ua cas, tiamsis yog tsis qhia, mas peb tsis muaj cuab kav yuav
pomzoo pub koj tus menyuam tau txais mov noj dawb lossis luv nqi mov.
Koj yuav tsum qhia tus xaus-saus nabnpawb ntawm tus laus muaj hnub nyoog
ntawm tsevneeg uas xee tsab ntawv thov no rau. Tsis tas muab tus
xaus-saus yog ua thov rau tus menyuam txais los tu lossis yog koj qhia
tias tau txais Food Stamp Program, Program Pab Rau Tsevneeg Txom Nyem
(TANF) lossis yog muaj tus case nabnpawb qhia tias tau txais Zaub Mov
Faib Pub Noj Hauv Khab Zos (FDPIR), lossis lwm hom kev pab FDPIR uas
muaj tus nabnpawb rau koj tus menyuam lossis yog koj qhia tias tus laus
muaj hnub nyoog hauv tsevneeg uas xee tsab ntawv thov thab niam muaj
xaus-saus nabnpawb. Peb yuav siv cov lus muab tuaj txiav txim xyuas saib
koj tus menyuam puas muaj cuab kav tau txais mov noj dawb lossis luv nqi
mov, thiab khiav tej haujlwm tswjfwm xyuas txog tej kev pab txog noj su
thiab noj tshais. TEJZAUM pej kuj muab cov ntaubntawv qhia txog kam tau
txais mov noj ntawd pub rau tej programs txog kev kawmntawv, kev noj qab
nyob huv, thiab kev noj haus kom pab lawv ntsuas xyuas, muab nyiaj pab,
lossis txiav txim saib yuav muaj dab tsi zoo pab rau lawv cov programs,
pub rau cov neeg kuaj xyuas cov programs, thiab cov cob-nab-thib tswjfwm
xyuas txog tej haujlwm no xyuas saib puas muaj leejtwg ua txhaum tej kev
cai.

Lus Txog Tsis Pub Txhob Txwm Xyeej Tsis Nyiam: Nov qhia txog tias yog
koj xav tias luag ua tsis ncaj rau koj mas koj yuav tsum ua li cas. Raws
li Tseemfwv tebchaws txoj cai thiab txoj cai nyob rau U.S. Department of
Agiculture, mas qhov chaw no tsis pub xwb tim lim hiam xyeej tsis kam
vim nqaij tawv, xim nqaij, lub tebchaws tus neeg tuaj, pojniam lossis
txivneej, hnub nyoog, lossis muaj mob xiam oob khab. Yog yuav ua
ntaubntawv foob tias luag txhob txwm lim hiam xyeej tsis kam, mas yuav
tsum sau mus rau USDA, Director, Office of Civil Rights, 1400
Independence Avenue, SW, Washington DC 20250-9410 lossis hu rau
800-795-3272 lossis 202-720-6382 (TTY). USDA yog ib qhov chaw pab thiab
chaw ntiav neeg ncaj ncees rau sawvdaws.

**PEB TAU KUAJ XYUAS KOJ TSAB NTAWV TEEV NPE**

Tsev kawmntawv:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Hnub tim: \_\_\_\_\_\_\_\_\_\_\_

Txog \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_:

Peb tau kuaj xyuas cov ntaubntawv koj xa tuaj rau peb ua povthawj tias
\[**names of children\]** muaj cuab kav tau txais mov noj dawb lossis
luv nqi mov, es peb tau txiav txim tias:

-   Qhov koj tus menyuam tau txais ntawd tsis hloov.

-   Pib **\[date\]** mus, qhov koj cov menyuam tau txais yuav raug hloov
    ntawm **tau tu nqi luv mov** **mus rau tau noj dawb** vim tias koj
    qhov nyiaj tau los ntawd poob ncaj raws li tus cai tau mov noj dawb.
    Koj cov menyuam yuav tau mov noj dawb tsis them nyiaj dab tsi li.

-   Pib **\[date\]** mus, qhov koj cov menyuam tau txais yuav raug hloov
    ntawm **tau mov noj dawb** **mus rau tau mov luv nqi noj** vim koj
    qhov nyiaj tau ntau tshaj qhov kam pub dawb. Tu nqi luv rau mov mas
    yog **\[\$\]** rau pluas su thiab **\[\$\]** rau pluas tshais.

-   Pib **\[date\]** mus, **koj cov menyuam yuav tsis tau txais mov noj
    dawb** lossis luv nqi mov noj lawm vim li hais hauv qab no:

> \_\_\_ Tej ntaubntawv qhia tias koj tsis tau txais Food Stamps, lossis
> TANF.
>
> \_\_\_ Tej ntaubntawv qhia tias tus menyuam lossis cov menyuam tsis
> yog tsis muaj tsev\
> nyob, tsis yog khiav tawm tsev, lossis tsis yog ib sij tsiv ua zog ib
> qho chaw rau ib qho.
>
> \_\_\_ Koj qhov nyiaj tau los ntau tshaj qhov luag phua tseg tias puas
> tau txais mov noj dawb lossis luv nqi mov.
>
> \_\_\_ Koj tsis xa cov ntaubntawv:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> no tuaj.
>
> \_\_\_ Koj tsis teb tej peb kom koj ua xa tuaj.
>
> Zaubmov raug nyiaj **\[\$\]** rau pluas su thiab **\[\$\]** rau plua
> tshais. Yog koj tsevneeg qhov nyiaj tau los poob qis lossis koj
> tsevneeg muaj coob ntxiv, mas koj muaj cuab kav ua ntawv thov dua. Yog
> yav tag los koj tsis tau muab tej ntaubntawv xa tuaj qhia tias koj
> muaj cuab kav tau txais, mas thaum koj rov ua ntaubntawv thov mas luag
> yuav hais kom koj muab tej ntaubntawv no tuaj.

Yog koj tsis txaus siab rau qhov tau txiav txim, mas thov koj tham nrog
**\[name\]** ntawm **\[phone\]**. Koj kuj muaj cai kom luag ua ncaj
ncees mloog koj zaj lus. Yog koj hais kom luag mloog koj zaj lus ua ntej
**\[date\]**, mas koj tus menyuam muaj cuab kav tau txais mov noj dawb
lossis luv nqi mov mus txog ntua rau thaum luag mloog koj zaj lus tag es
luag rov txiav txim. Koj muaj cuab kav thov kom luag mloog koj zaj lus
yog koj hu rau lossis sau ntawv rau: **\[name\], \[address\], \[phone
number\]**.

Ua Tsaug,

**\[signature\]**

**Lus Txog Tsis Pub Txhob Txwm Xyeej Tsis Nyiam:** Nov qhia txog tias
yog koj xav tias luag ua tsis ncaj rau koj mas koj yuav tsum ua li cas.
Raws li Tseemfwv tebchaws txoj cai thiab txoj cai nyob rau U.S.
Department of Agiculture, mas qhov chaw no tsis pub xwb tim lim hiam
xyeej tsis kam vim nqaij tawv, xim nqaij, lub tebchaws tus neeg tuaj,
pojniam lossis txivneej, hnub nyoog, lossis muaj mob xiam oob khab. Yog
yuav ua ntaubntawv foob tias luag txhob txwm lim hiam xyeej tsis kam,
mas yuav tsum sau mus rau *USDA, Director, Office of Civil Rights, 1400
Independence Avenue, SW, Washington DC 20250-9410* lossis hu rau
800-795-3272 lossis 202-720-6382 (TTY). USDA yog ib qhov chaw pab thiab
chaw ntiav neeg ncaj ncees rau sawvdaws.

February 2006 Letter of Verification Results

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