NACP: 2021-2022 Application for Free and Reduced-Price Meals

Application for Free and Reduced-Price Meals

Complete one application per household
Please read the instructions on how to apply. Print clearly with a pen. This institution is an equal opportunity provider.

California Education Code Section 49557(a): Applications for free and reduced-price meals may be submitted at any time during a school day. Children participating in the federal National School Lunch Program will not be overtly identified by the use of special tokens, special tickets, special serving lines, separate entrances, separate dining areas, or by any other means.
Family Name*
Select No of Students for Enrollment*

1234
Student Information
Student 1 Information
Student 1 Name*

First NameMiddle NameLast Name
School Name
Grade-Level for 2021-2022 school year*
D.O.B

MonthDayYear
Date
Check the applicable*

FosterHomelessHomelessRunaway
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

Hispanic or LatinoNot Hispanic or Latino
Race

American Indian or Alaskan NativeNative Hawaiian or other Pacific IslanderAsianBlack or African AmericanWhite
Student 2 Information
Student 2 Name*

First NameLast Name
School
Grade-Level for 2020-2021 school year*
D.O.B

MonthDayYear
Date
Check the applicable*

FosterHomelessHomelessRunaway
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

Hispanic or LatinoNot Hispanic or Latino
Race

American Indian or Alaskan NativeNative Hawaiian or other Pacific IslanderAsianBlack or African AmericanWhite
Student 3 Information
Student 3 Name*

First NameLast Name
School
Grade-Level for 2020-2021 school year*
D.O.B

MonthDayYear
Date
Check the applicable*

FosterHomelessHomelessRunaway
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

Hispanic or LatinoNot Hispanic or Latino
Race

American Indian or Alaskan NativeNative Hawaiian or other Pacific IslanderAsianBlack or African AmericanWhite
Student 4 Information
Student 4 Name*

First NameLast Name
Teacher's Name
Grade-Level for 2020-2021 school year*
D.O.B

MonthDayYear
Date
Check the applicable*

FosterHomelessHomelessRunaway
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

Hispanic or LatinoNot Hispanic or Latino
Race

American Indian or Alaskan NativeNative Hawaiian or other Pacific IslanderAsianBlack or African AmericanWhite
Step-2 ASSISTANCE PROGRAMS: CalFresh, CalWORKs, or FDPIR
Do ANY household members (child or adult) currently participate in CalFresh, CalWORKs or FDPIR?

YesNo
Check the applicable program box, enter one case number*

CalFreshCalWORKsFDPIR
Case Number*
Step-3 REPORT INCOME FOR ALL HOUSEHOLD MEMBERS

STUDENT INCOME: Sometimes students in the household earn income. Enter the TOTAL GROSS income (before deductions) in whole dollars earned by all students
Total Student Income ($)
How Often

WeeklyBiweeklyTwice a MonthMonthlyYearly
ALL OTHER HOUSEHOLD MEMBERS (including yourself): List ALL household members not listed in STEP 1, even if they do not receive income. For each household member, report the TOTAL GROSS income (before deductions) in whole dollars for each source. If the household member does not receive income from any sources, write “0”. If you enter “0” or leave any fields blank, you are certifying (promising) that there is no income to report.
Member 1 Information
Member 1 Name

First NameLast Name
Earning From Work ($)
How Often

WeeklyBiweeklyTwice a MonthMonthlyYearly
Public Assistance/SSI/Child Support/Alimony ($)
How Often

WeeklyBiweeklyTwice a MonthMonthlyYearly
Pensions/Retirement/All Other Income ($)
How Often

WeeklyBiweeklyTwice a MonthMonthlyYearly
Member 2 Information
Member 2 Name

First NameLast Name
Earning From Work ($)
How Often

WeeklyBiweeklyTwice a MonthMonthlyYearly
Public Assistance/SSI/Child Support/Alimony ($)
How Often

WeeklyBiweeklyTwice a MonthMonthlyYearly
Pensions/Retirement/All Other Income ($)
How Often

WeeklyBiweeklyTwice a MonthMonthlyYearly
Member 3 Information
Member 3 Name

First NameLast Name
Earning From Work ($)
How Often

WeeklyBiweeklyTwice a MonthMonthlyYearly
Public Assistance/SSI/Child Support/Alimony ($)
How Often

WeeklyBiweeklyTwice a MonthMonthlyYearly
Pensions/Retirement/All Other Income ($)
How Often

WeeklyBiweeklyTwice a MonthMonthlyYearly
Member 4 Information
Member 4 Name

First NameLast Name
Earning From Work ($)
How Often

WeeklyBiweeklyTwice a MonthMonthlyYearly
Public Assistance/SSI/Child Support/Alimony ($)
How Often

WeeklyBiweeklyTwice a MonthMonthlyYearly
Pensions/Retirement/All Other Income ($)
How Often

WeeklyBiweeklyTwice a MonthMonthlyYearly
Total Household Members

ChildrenAdults
Enter the last four digits of Social Security number (SSN) fromthe Primary Wage Earner or Other Adult Household Member
*

Check the box if NO SSN
Adult Information Completing Form
Name*

First NameLast Name
Home Phone
Cell Phone
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Certification*

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.
Submitter's Signature*

Clear
Submitter's E-mail*
example@example.com
Annual Income Conversion:
Weekly x52
Bi-weekly x26
Twice a Month x24
Monthly x12
How Often?

WeeklyBi-WeeklyTwice a MonthMonthlyYearly
Total Household Size
Total Household Income
Categorical
Error Prone
Eligibility Status

FreeReduced PricePaid (Denied)
Verified As

HomelessMigrantRunaway
Determining Official's Signature
Confirming Official's Signature
Verifying Official's Signature
Date*

MonthDayYear
Date
Should be Empty:

Application for Free and Reduced-Price Meals

Student Information