Moulton ISD, 2020-2021 Standard (Multi-Child) Application for Free and Reduced-Price School Meals Complete one application per household. Please use a pen (not a pencil).	This Box for School Use Only. Date Withdrawn:

Step 1:	Definition of Household Member: anyone who is living with you and shares income and expenses, even if not related. Children in Foster care; children who meet the definition of Homeless, Migrant, or Runaway or who participate in Head Start are eligible for free meals. Please read the directions for more information.
A. List ALL Household Members Who Are Infants, Children, and Students up to and Including Grade 12. If more spaces are needed, use the Additional Names section on the back.
List each child’s name.	Student Attends School in District?	Grade	Optional: Student ID Number	Check all that apply.
First Name	MI	Last Name	Yes No	Foster	Head Start	Homeless	Migrant	Runaway
1.	c c	c	c	c	c	c
2.	c c	c	c	c	c	c
3.	c c	c	c	c	c	c
4.	c c	c	c	c	c	c
B. Participation in a Categorical Program
• every child skip complete listed in Step 1 is a participant any one of the following programs—Foster, Head Start, Homeless, Migrant, or Runaway, Step 2 and Step 3. • every child skip complete listed in Step 1 is a participant any one of the following programs—Foster, Head Start, Homeless, Migrant, or Runaway, Step 2 and Step 3.
• any Household Members (including you) currently participate in SNAP, TANF, and/or FDPIR? SNAP, TANF, or FDPIR: • any Household Members (including you) currently participate in SNAP, TANF, and/or FDPIR? SNAP, TANF, or FDPIR:
If complete Yes to SNAP/TANF Write skip complete If complete Yes to SNAP/TANF Write skip complete Steps 2 and 3. If > the Eligibility Determination Group (EDG) number in this space ____________________, Step 2, and Step 3. Yes FDPIR, skip complete If to check this box c, Step 2, and Step 3.

Step 2:	Please read the directions for more information for the following questions.
Report Income for ALL Household Members (Skip this step if you entered an EDG number or checked the box to indicate participation in FDPIR in Step 1).
A. Last Four Digits of Social Security Number (SSN) of an Adult Household Member:	XXX-XX	__	__	__	__	o Check if no SSN
B. Income for Adult Household Members (Include Yourself, But Not Children. If more spaces are needed, use the Additional Names section on the back.)
List even if they do not receive income. List even if they do not receive income. all Household Members listed in STEP 1 (including yourself) For each Household Member listed, if they do receive income, report total income (without deductions) for each source in whole dollars only. Indicate the frequency of income: W=Weekly, E=Every 2 Weeks, T=Twice per Month, M=Monthly, A=Annually. If they do not receive income from any source, write ‘0.’ If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.
Adult’s First/Last Name (Do not include the income of children in this section. The income of children goes in 2C.)	Work Earnings (Enter Amount)	Frequency (Circle One)	Public Assistance/ Child Support/ Alimony (Enter Amount)	Frequency (Circle One)	Pensions/Retirement/ Social Security/Supplemental Security Income (Enter Amount)	Frequency (Circle One)	All Other (Enter Amount)	Frequency (Circle One)
1.	$	W–E–T–M–A	$	W–E–T–M–A	$	W–E–T–M–A	$	W–E–T–M–A
2.	$	W–E–T–M–A	$	W–E–T–M–A	$	W–E–T–M–A	$	W–E–T–M–A
3.	$	W–E–T–M–A	$	W–E–T–M–A	$	W–E–T–M–A	$	W–E–T–M–A
C. Income for Children in the Household (Do not include adult income. Do report any type of regular income for children in the household. If more spaces are needed, use the Additional Names section on the back.)
Record total income by frequency for each child who receives regular income listed in Step 1.	Weekly	Every 2 Weeks	Twice per Month	Monthly	Annually
1.	$	$	$	$	$
2.	$	$	$	$	$
3.	$	$	$	$	$
D. Total Household Members (Count all children & adults living in the household)	_____

Step 3:	Please read the directions for more information on signing this form.
Provide Contact Information and Adult Signature. Return this application to Moulton ISD Lunchroom, (361)596-7578, rbartos@multonisd.net.
I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.

Street Address/Apt #	City	State	Zip	Daytime Phone and Email (Optional)
Printed Name of Adult Household Member Signing the Form	Signature of Adult Household Member Signing the Form	Today’s Date

Step 1:	Additional Names
A. List ALL Household Members Who Are Infants, Children, and Students up to and Including Grade 12. If more spaces are needed, use the Additional Household Member Sheet on the back.
List each child’s name.	Student Attends School in	Grade	Optional:	Check all that apply.

April 15, 2020