**PROTOTYPE**

**DISCLOSURE OF FREE AND REDUCED PRICE INFORMATION**

**AGREEMENT**

**I. PURPOSE AND SCOPE**

[(Insert name of determining agency)]{.underline} and [(insert name of
receiving agency]{.underline}) acknowledge and agree that children\'s
free and reduced price meal and free milk eligibility information
obtained under provisions of the National School Lunch Act (42 USC 1751
et. seq.) or Child Nutrition Act of 1966 (42 USC 1771 et. seq.) and the
regulations implementing those Acts is confidential information. This
Agreement is intended to ensure that any information disclosed by the
[(insert name of determining agency]{.underline}) to the [(insert name
of receiving agency]{.underline}) about children eligible for free and
reduced price meals or free milk will be used only for purposes
specified in this Agreement and that the [(insert name of determining
agency]{.underline}) and ([insert name of receiving agency)]{.underline}
recognize that there are penalties for unauthorized disclosures of this
eligibility information.

**II. AUTHORITY**

Section 9(b)(2)(C)(iii) of the National School Lunch Act (42 USC
1758(b)(2)(C)(iii)) authorizes the limited disclosure of children\'s
free and reduced price meal or free milk eligibility information to
specific programs or individuals, without prior parent/guardian consent.
Except that, the parent/guardian must be provided the opportunity to
decline to share eligibility information prior to the disclosure for
identifying children eligible for benefits under or enrolling children
in the State Medicaid Program and the State children\'s health insurance
program. Additionally, the statute specifies that for any disclosures
not authorized by the statute, the consent of children\'s
parents/guardians must be obtained prior to the disclosure.

The *requesting* agency certifies that it is currently authorized to
administer the following program(s) and that information requested will
only be used by the program(s) indicated:

+--------+--------------------------------+----------------------------+
| *      | **Program**                    | **Information authorized** |
| *Check |                                |                            |
| all    |                                |                            |
| that   |                                |                            |
| a      |                                |                            |
| pply** |                                |                            |
+--------+--------------------------------+----------------------------+
|        | *Medicaid* or the *State       | All eligibility            |
|        | children's health insurance    | information, unless        |
|        | program (SCHIP),* administered | parents elect not to have  |
|        | by a State or local agency     | information disclosed.     |
|        | authorized under titles XIX or |                            |
|        | XXI of the Social Security     |                            |
|        | Act.                           |                            |
|        |                                |                            |
|        | Specify Program:               |                            |
+--------+--------------------------------+----------------------------+
|        | *State health program* other   | Eligibility **status**     |
|        | than Medicaid/SCHIP,           | only; consent not          |
|        | administered by a State agency | required.                  |
|        | or local education agency.     |                            |
|        |                                |                            |
|        | Specify Program:               |                            |
+--------+--------------------------------+----------------------------+
|        | *Federal health program* other | NO eligibility             |
|        | than Medicaid/SCHIP            | information, unless        |
|        |                                | parental consent is        |
|        | Specify Program:               | obtained.                  |
+--------+--------------------------------+----------------------------+
|        | *Local health program*         | NO eligibility             |
|        |                                | information, unless        |
|        | Specify Program:               | parental consent is        |
|        |                                | obtained                   |
+--------+--------------------------------+----------------------------+
|        | *Child Nutrition Program*      | All eligibility            |
|        | under the National School      | information; consent not   |
|        | Lunch Act or Child Nutrition   | required.                  |
|        | Act                            |                            |
|        |                                |                            |
|        | Specify Program:               |                            |
+--------+--------------------------------+----------------------------+
|        | *Federal/State or local means  | Eligibility **status**     |
|        | tested nutrition program* with | only; consent not          |
|        | eligibility standards          | required.                  |
|        | comparable to the National     |                            |
|        | School Lunch Program           |                            |
|        |                                |                            |
|        | Specify Program:               |                            |
+--------+--------------------------------+----------------------------+
|        | *Federal education program*    | Eligibility **status**     |
|        |                                | only; consent not          |
|        | Specify Program:               | required.                  |
+--------+--------------------------------+----------------------------+
|        | *State education program*      | Eligibility **status**     |
|        | administered by a State agency | only; consent not          |
|        | or local education agency      | required.                  |
|        |                                |                            |
|        | Specify Program:               |                            |
+--------+--------------------------------+----------------------------+
|        | *Local education program*      | NO eligibility             |
|        |                                | information, unless        |
|        | Specify Program:               | parental consent is        |
|        |                                | obtained                   |
+--------+--------------------------------+----------------------------+

***Note**:* Section 9(b)(2)(C)(iv) specifies that certain programs may
receive children\'s eligibility status **only**, without parental
consent. Parental consent must be obtained to disclose any additional
eligibility information. Section 9(b)(2)(C)(iv) specifies that for State
Medicaid or SCHIP, parents must be notified and given opportunity to
elect not to have information disclosed. Social security numbers may
only be disclosed if households are given notice of the disclosure and
the uses to be made of their social security numbers as required by Sec.
7 of the Privacy Act.

**III. RESPONSIBILITIES**

[**(***Insert Name of Determining Agency**)***]{.underline} will**:**

When required, secure parents/guardians consent prior to any disclosure
not authorized by the National School Lunch Act or any regulations under
that Act, unless prior consent is secured by the receiving agency and
made available to the determining agency;

For State Medicaid and SCHIP notify parents/guardians of potential
disclosures and provide opportunity for parents/guardians to elect not
to have information disclosed;

Disclose eligibility information only to persons directly connected to
the administration or enforcement of programs authorized access under
the National School Lunch Act or regulations under the Act or to
programs or services for which parents/guardians gave consent.

*[(Insert Name of Receiving Agency]{.underline}**)*** will**:**

Ensure that only persons who are directly connected with the
administration or enforcement of the *(insert name of the Program)* and
whose job responsibilities require use of the eligibility information
will have access to children\'s eligibility information:

[(Specify by name(s) or
title(s)]{.underline})\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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Use children\'s free and reduced price eligibility information for the
following specific purpose(s):

[(Describe]{.underline})\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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Inform all persons that have access to children\'s free and reduced
price meal eligibility information that the information is confidential,
that children\'s eligibility information must only be used for purposes
specified above, and the penalties for unauthorized disclosures.

Protect the confidentiality of children\'s free and reduced price meal
or free milk eligibility information as follows:

[(Specifically describe how the information will be protected from
unauthorized uses and further
disclosures]{.underline}.)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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**Description of Procedures to Transfer Meal Eligibility Information**
(May be completed by either the determining agency or receiving agency)

Describe the procedures for transferring students\' meal eligibility
information from the determining agency to the requesting agency/program
so as to limit the number of individuals who have access to the
information.

[(Describe]{.underline})\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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**IV. EFFECTIVE DATES**

This agreement shall be effective
from\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ to
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**V. PENALTIES**

Any person who publishes, divulges, discloses, or makes known in any
manner, or to any extent not authorized by Federal law (Section
9(b)(2)(C) of the National School Lunch Act; 42 USC 1758(b)(2)(C)) or a
regulation, any information about a child\'s eligibility for free and
reduced price meals or free milk shall be fined not more than a \$1,000
or imprisonment of not more than 1 year or both.

**VI. SIGNATURES**

The parties acknowledge that children\'s free and reduced price meal and
free milk eligibility information may be used only for the specific
purposes stated above; that unauthorized use of free and reduced price
meal and free milk information or further disclosure to other persons or
programs is prohibited and a violation of Federal law which may result
in civil and criminal penalties.

**Requesting Agency/Program Administrator**

Printed
Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Title:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Determining Agency Administrator**

Printed
Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Title:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\*Any attachments will become part of this agreement.