INSTRUCTIONS

Sources of Income

Sources of Income for Children	Sources of Income for Adults

Sources of Child Income	Example(s)	Earnings from Work	Public Assistance / Alimony / Child Support	Pensions / Retirements / All Other Income
- Earnings from work	- A child has a regular full or part-time job where they earn a salary or wages	- Salary, wages, cash bonuses - - Net Income from self-employment - (farm or business) - - If you are in the U.S. Military: - - - Basic pay and cash bonuses (do - NOT include combat pay, FSSA or - privatized housing allowances) - Allowances for off-base housing, food and clothing housing allowances) - Allowances for off-base housing, food and clothing	- Unemployment benefits - - Worker’s compensation - Supplemental Security Income (SSI) - - Cash assistance from State or local government - Alimony payments - - Child support payments - Veteran’s benefits - - Strike benefits - - - -	- Social Security (including railroad retirement and black lung benefits) - Private pensions or disability benefits - Regular income from trusts or estates - Annuities - Investment income - Earned interest - Rental income - Regular cash payments from outside household Earned interest - Rental income - Regular cash payments from outside household
- Social Security - Disability Payments - Survivor’s Benefits	- A child is blind or disabled and receives Social Security benefits - A Parent is disabled, retired, or deceased, and their child receives Social Security benefits
- Income from person outside the household	- A friend or extended family member regularly gives a child spending money
- Income from any other source	- A child receives regular income from a private pension fund, annuity, or trust	privatized housing allowances) - Allowances for off-base housing, food and clothing	- Salary, wages, cash bonuses - - Net Income from self-employment - (farm or business) - - If you are in the U.S. Military: - - - Basic pay and cash bonuses (do - NOT include combat pay, FSSA or - privatized housing allowances) - Allowances for off-base housing, food and clothing housing allowances) - Allowances for off-base housing, food and clothing	- Unemployment benefits - - Worker’s compensation - Supplemental Security Income (SSI) - - Cash assistance from State or local government - Alimony payments - - Child support payments - Veteran’s benefits - - Strike benefits - - - -	- Unemployment benefits - - Worker’s compensation - Supplemental Security Income (SSI) - - Cash assistance from State or local government - Alimony payments - - Child support payments - Veteran’s benefits - - Strike benefits - - - - - - -	- Earned interest - Rental income - Regular cash payments from outside household	- Social Security (including railroad retirement and black lung benefits) - Private pensions or disability benefits - Regular income from trusts or estates - Annuities - Investment income - Earned interest - Rental income - Regular cash payments from outside household Earned interest - Rental income - Regular cash payments from outside household

OPTIONAL Children's Racial and Ethnic Identities We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children’s eligibility for free or reduced price meals. ☐

Ethnicity (check one):

Race (check one or more):

Black or African American Native Hawaiian or Other Pacific Islander White

Hispanic or Latino Not Hispanic or Latino

American Indian or Alaskan Native

Asian Asian

The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules. In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET

Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28- 17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

1. mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or 2. fax: (833) 256-1665 or (202) 690-7442; or 3. email: program.intake@usda.gov

This institution is an equal opportunity provider.

DO NOT FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY.

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12 q q q q q Total Income: Per: Week, Every 2 Weeks, Twice A Month, Month, Year Household size: Date Received: Dual Eligibility: Foster child(ren) – Free Non-foster child(ren) – Free Reduced Denied \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ q q q q q q Directly Certified: Extended Benefit Foster Child Migrant Homeless Runaway Approved by Principal q q Categorical Eligibility: SNAP/TANF based on provided number Foster Child on an application q q qDenied Eligibility: Free Reduced Reason: Date Withdrawn: q q q q q Incomplete/Missing: SS# HH Members Signature Income Frequency Other

Determining Official’s Signature: Date:

Confirming Official’s Signature: Date: Verifying Official’s Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_