November 2, 2011
Child and Adult Care Food Program Applicants
CIVIL RIGHTS
NON-DISCRIMINATION STATEMENTS
The Office of Child Nutrition has been notified by the United States Department of Agriculture (USDA) of
changes in regulations regarding Civil Rights in Child Nutrition Programs. The Civil Rights language
used for the non-discrimination poster, news releases and publications has changed. If you have
already printed materials for this program year, you do not have to make changes at this time.
The non-discrimination and complaint statements must appear on all program materials produced by
child care facility. This includes menus, parent information and handbooks, websites, bid documents as
well as, information given to parents regarding Child Nutrition Programs. The revised language reads:
In accordance with Federal law and U.S. Department of Agriculture (USDA) policy, this
institution is prohibited from discriminating on the basis of race, color, national origin,
sex, age, or disability.
To file a complaint alleging discrimination, write USDA, Director, Office of Civil Rights,
1400 Independence Avenue SW, Washington, DC 20250-9410 or call, toll free, (866)
632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities
may contact USDA through the Federal Relay Service at (800) 877-8339; or (800)
845-6136 (Spanish). USDA is an equal opportunity provider and employer.
If material is too small to include the full statement or if the material is only one page (such as menus),
the material must, at a minimum, include the following statement:
“This institution is an equal opportunity provider.”
The print size of this statement cannot be smaller than the text of the material.
Posters: You are required to display the non-discrimination poster in a visible location in your center.
Posters are available in the Office of Child Nutrition by calling 304-558-3396. The new civil rights
statement is not updated on the poster please be sure to use the statement above. If you need a copy
please contact this office at 304-558-3396.
Sincerely,
Richard J. Goff, Executive Director
Office of Child Nutrition
GC/ja
CIV_R2011CACFP/L:/CACFP/Corr/FY2011
1
Free
and
Reduced- Price Meals Household Application for 2012- 2013— West Virginia Dept. of Education
USE BLACK OR DARK BLUE INK, PRINT NEATLY. COMPLETE ONE APPLCIATION PER HOUSEHOLD
1. Names of ALL Children in School, Center, or Camp
Date
First Name
Last Name
Mark if
Birth
Foster
School, Center, or Camp
Grade
Ct7
5
Sri 4'
Srn
of
MM/DD/ YY
MI
k
o.
El
aria
I
I
i
0
2. SNAP/ TANF NUMBER
SNAP
TANF
If any member of your household receives SNAP or TANF, indicate which program and provide the 1O- digit case#
If any, SKIP TO PART 5)
3. HOMELESS, MIGRANT, RUNAWAY
If the child you are applying for is homeless, migrant, or runaway, check the appropriate box and call your county contact at
Homeless
Mi rant Runaway
4. HOUSEHOLD MEMBERS AND GROSS INCOME FROM LAST MONTH
List each person in the household. For each person who receives income, write the amount received and fill in how often it is received.
Name( Last,
List
everyone
Attach
Monthly Earnings
First2
in the Household.
a separate sheet
if
Monthly
Welfare,
Before Deductions)
Payments
Other
from
Child Support,
Su
Social
Monthly
Income
Pensions, Retirement,
Alimony
needed.
TOr-
Check
if no
Income
Security
DUO
ra
=`
1-11
i
15j-n•
rch
I
Monthly
from Work
5 rrit-
cun
Total Number
of
Lj
Persons in Household
Total
Monthly Income Before Deductions$
3(e0 o, can
5. Signature and Social Security Number ( Adult must sign.)
An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list the last 4 digits of his or her
Social Security Number or mark the" I do not have a Social Security Number" box. ( See Privacy Act Statement on the back of this page)
I certify( promise) that all information on this application is true and that all income is reported. I understand that the school system may get federal funds based on the information I
give. I understand that school officials may verify( check) the information. I understand that if I purposely give false information, my child(ren) may lose meal benefits, and I may be
Last 4 Di its of Social Security Number
Today' s Date
prosec
4./
2. 0?
0
ettti
1
3
*****
Z 3
1
7
I do not have a Social Security Number
Sigitur`
Sr-
1
o
Th
12.3
- 12
12
Work Phone Number
Home Phone Number
Printed Name
Mailing
- 6 6`.
46-
111 nr
14-cppyv( IIe.
u-c,
I23y 5
6u v
State
City
Address
ZIP Code
6. Children' s Race and Ethnicity-( You do not have to complete this part to receive free and reduced price meals.)
Mark one or more racial identities from this group:
American Indian
Asian
Black
or
or
White
Alaska Native
Native Hawaiian or Other Pacific Islander
African American
And mark one ethnic identity from this group:
Hispanic
or
Not Hispanic or Latino
Latino
7. Other Benefits - ( You do not have to complete this part to receive free and reduced price meals.)
Yes, school officials may use the information provided on this application to determine my child( ren)' s eligibility for free textbooks,
workbooks, and other school supplies.
Do not fill out this part. This is for sponsor' s use only. Annual Income Conversion: WeeklyX 52. Every 2 Weeks X 26, Twice A Month X 24, MonthlyX 12
Categorically Eligibility:
-
or-
Income
Eligibility:
Vi
Free Meals
Reduced Meals
Temporary Free: Time Period
Temporary Reduced: Time Period
Denied: R easgn:
Signature/ Stamp
Verification:
of
Approving
Official
C
p
r`
d (_
1).-
A- (
4z, N..,
2-1-
13
Date Withdrawn
Date
Confirming Official' s Signature
Date
Follow- up Official' s Signature
WVDE- ADM- 12r
Date Approved
Continue
on
Back"
2•
Free
Reduced- Price Meals Household Application for 2012- 2013— West Virginia Dept. of Education
and
USE BLACK OR DARK BLUE INK. PRINT NEATLY. COMPLETE ONE APPLCIATION PER HOUSEHOLD
1.
Names of ALL Children in School, Center, or Camp
SY, r, l 4
Date of Birth
Mark if
MM/DD/ YY
Foster
MI
First Name
Last Name
Grade
School, Center, or Camp
b.
c r&
2. SNAP/ TANF NUMBER
SNAP
TANF
If any member of your household receives SNAP or TANF, indicate which program and provide the 10- digit case*
If any, SKIP TO PART 5)
3. HOMELESS, MIGRANT, RUNAWAY
If the child you are applying for is homeless, migrant, or runaway, check the appropriate box and call your county contact at
Homeless Mi rant Runaway
4. HOUSEHOLD MEMBERS AND GROSS INCOME FROM LAST MONTH
List each person in the household. For each person who receives income, write the amount received and fill in how often it is received.
Monthly
Name( Last, First)
List
everyone
ry
Attach
a separate sheet
h
S
1.: 5a
if
Earnings
Monthly
from Work
in the Household.
Before Deductions)
Payments
Other
from
Social
Monthly
Income
Pensions, Retirement,
Alimony
needed.
1
Monthly
Welfare,
Child Support,
Check
if no
Income
Security
4 l
5('r klr.
5'r
r
13 r'.o"
- -
rani M
Total Number
of
4
Persons in Household
Total Monthly Income Before Deductions$
5. Signature and Social Security Number ( Adult must sign.)
An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list the last 4 digits of his or her
Social Security Number or mark the" I do not have a Social Security Number" box. ( See Privacy Act Statement on the back of this page)
I certify( promise) that all information on this application is true and that all income is reported. I understand that the school system may get federal funds based on the information I
give. I understand that school officials may verify( check) the information. I understand that if I purposely give false information, my child(ran) may lose meal benefits, and I may be
Toda ' s Date
prosecuted.,
Last 4 Digits of Social Security Number
0
04...„
2p
T
1 3
*****
I 23
4
I do
not
have
a
Social
Security
Number
1
Signature
L,
st;4.
Sr -,14- k
21,
6.
L-41
P,/
f(
w
Mailing
Address
1212
SoyHome Phone Number
Printed Name
.
I
City
Children' s Race
Ethnicity-(
and
Work Phone Number
p .iui/lit
23 / 54
u v
State
ZIP Code
You do not have to complete this part to receive free and reduced price meals.)
Mark one or more racial identities from this group:
American Indian
Asian
Black
or
or
White
Alaska Native
Native Hawaiian or Other Pacific Islander
African American
And mark one ethnic identity from this group:
Hispanic
or
Not Hispanic or Latino
Latino
7. Other Benefits -( You do not have to complete this part to receive free and reduced price meals.)
Yes, school officials may use the information provided on this application to determine my child( ren)' s eligibility for free textbooks,
workbooks, and other school supplies.
Do not fill out this part. This is for sponsor' s use only. Annual Income Conversion: WeeklyX 52. Every 2 Weeks X 26, Twice A Month X 24, MonthlyX 12
Categorically Eligibility"
-
Or-
Income
Eligibility:
N
Free Meals
Reduced Meals
Temporary Free: Time Period
Temporary Reduced: Time Period
Denied: _Reason:
C' `
1,
Signature/ Stamp
Verification:
of
Approving Official
Confirming
ti o&,
eCLA-C... CtL,*_ C 4'.+._
ApprovedZ'' /
3
Date Withdrawn
Date
Official' s Signature
Date
Follow- up Official' s Signature
WVDE- ADM- 121
y
Date
Continue on Back"
I
3.
Free
and
Reduced- Price Meals Household Application for 2012- 2013— West Virginia Dept. of Education
USE BLACK OR DARK BLUE INK. PRINT NEATLY. COMPLETE ONE APPLCIATION PER HOUSEHOLD
1. Names of ALL Children in School, Center, or Camp
Date
First Name
Last Name
of
Birth
Mark if
Foster
MM/DD/Y
MI
School, Center, or Camp
Grade_.
I
4
I
I
I
I
I
I
SNAP/TANF NUMBER
2.
SNAP
TANF
'
If any member of your household receives SNAP or TANF, indicate which program and provide the 10- digit case#
Of any SKIP TO PART 5)
HOMELESS, MIGRANT, RUNAWAY
3.
If the
child you are
applying for is homeless,
migrant, or
Homeless
runaway,
check
the
box
appropriate
and call your
county
contact at
Migrant Runaway
LJ
4. HOUSEHOLD MEMBERS AND GROSS INCOME FROM LAST MONTH
List each person in the household. For each person who receives income, write the amount received and fill in how often it is received.
Monthly
Name( Last, First)
List
everyone
Attach
a separate sheet
if
Earnings
Monthly
from Work
in the Household.
Before Deductions)
150O,
Other
from
Social
Monthly
Income
Pensions, Retirement,
Alimony
needed.
lirrik-44-1
Monthly Payments
Welfare,
Child Su
Support,
ort,
Check
if no
Income
Security
$
i 00 Cs
5 -i
r
F1Jh
ria n
Total Number
of
Persons in Household
L-{
Total
Monthly
Income Before Deductions$
2'5o 6
5. Signature and Social Security Number ( Adult must sign.)
An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list the last 4 digits of his or her
Social Security Number or mark the" I do not have a Social Security Number" box. ( See Privacy Act Statement on the back of this page)
I certify( promise) that all information on this application is true and that all income is reported. I understand that the school system may get federal funds based on the information I
give. I understand that school officials may verify( check) the information. I understand that if I purposely give false information, my child(ren) may lose meal benefits, and I may be
Toda ' s Date
prosec
d.
Last 4 Di its of Social Security Number
r'rs..
r?
1
O 2• 0-7
t
I
3
* * ** *
31'1
1 .
I do not have a Social Security Number
Signature
I Sa.
,),- y,/--
a)y- 5S5- i2lz
h
12
Mailing
6.
Work Phone Number
Home Phone Number
Printed Name
PPy
Address
Children' s Race
and
1.c,.,,4„.
I- app iut11c
City
Ethnicity-(
t2.3(4 s
wt.
State
ZIP Code
You do not have to complete this part to receive free and reduced price meals.)
Mark one or more racial identities from this group:
American Indian
Asian
Black
or
African American
or
White
Alaska Native
Native Hawaiian or Other Pacific Islander
And mark one ethnic identity from this group:
Hispanic
7.
or
Latino
Not Hispanic or Latino
Other Benefits -( You do not have to complete this part to receive free and reduced price meals.)
Yes, school officials may use the information provided on this application to determine my child( ren)' s eligibility for free textbooks,
workbooks, and other school supplies.
Do not fill out this part. This is for sponsor' s use only. Annual Income Conversion: WeeklyX 52, Every 2 Weeks X 26, Twice A Month X 24, MonthlyX 12
Categorically Eligibility:
-
Or-
Income
Eligibility
`
4
Free Meals
Reduced Meals
Denied:
Signature/ Stamp
Verification:
of
Approving Official
C
r
A
A_. 0
Reason:
a (
y, _
WI
q
i
t.
Date Approved?
/—/
3
Date Withdrawn
Date
Confirming Official' s Signature
Date
Follow- up Official' s Signature
WVDE- ADM- 121
Temporary Free: Time Period
Temporary Reduced: Time Period
Continue
on
Back"
Free
Reduced- Price Meals Household Application for 2012- 2013— West Virginia Dept. of Education
and
USE BLACK OR DARK BLUE INK, PRINT NEATLY. COMPLETE ONE APPLCIATION PER HOUSEHOLD
1.
Names of ALL Children in School, Center, or Camp
Sm\ 4
Zrn‘ 4,
Date of Birth
Mark if
MM/DD/ YY
Foster
MI
First Name
Last Name
School, Center, or Camp
Grade
4.r,
I
a 1.-V1- h
/
0
I
I
2. SNAP/ TANF NUMBER
SNAP
TANF
If any member of your household receives SNAP or TANF. indicate which program and provide the 10- digit case#
If any, SKIP TO PART 5)
3. HOMELESS, MIGRANT, RUNAWAY
If the child you are applying for is homeless, migrant, or runaway, check the appropriate box and call your county contact at
Homeless Mi rant Runaway
4. HOUSEHOLD MEMBERS AND GROSS INCOME FROM LAST MONTH
List each person in the household. For each person who receives income, write the amount received and fill in how often it is received.
Monthly
Name( Last, First)
List
everyone
Attach
a separate sheet
if
Monthly
Monthly
Welfare,
Before Deductions)
Payments
Other
from
Child Support,
Su
Social
Monthly
Income
Pensions, Retirement,
Alimony
needed.
Cor.-%S Or.- t
LA Sat
Earnings
from Work
in the Household.
Check
if no
Income
Security
Too. Ot. $
Ski
375.° O
$
cYN I
rv. t
t
Total Number
of
Persons in Household
4
Total
Monthly
Income Before Deductions$
a$ 7 S. 60
5. Signature and Social Security Number ( Adult must sign.)
An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list the last 4 digits of his or her
Social Security Number or mark the" I do not have a Social Security Number" box. ( See Privacy Act Statement on the back of this page)
I certify( promise) that all information on this application is true and that all income is reported. I understand that the school system may get federal funds based on the information I
give. I understand that school officials may verify( check) the information. I understand that if I purposely give false information, my children) may lose meal benefits, and I may be
Today' s Date
Last 4 Di its of Social Security Number
prosecuted.
C.
t,
l-_.
#
yi•L
o • Cd
z '
31
* * ** * I
3
( /
I do not have a Social Security Number
Signa ure
Home Phone Number
Printed Name
A°
i
Mailing
t-Ck0e .
Address
6. Children'
s
Race
and
Ethnicity-(
Work Phone Number
W
apil\,\\
Ity
I
e
1 : z3SL
State
1
ZIP Code
You do not have to complete this part to receive free and reduced price meals.)
Mark one or more racial identities from this group:
American Indian
Asian
it"
Black
or
or
White
Alaska Native
Native Hawaiian or Other Pacific Islander
African American
And mark one ethnic identity from this group:
Hispanic
or
Not Hispanic or Latino
Latino
7. Other Benefits -( You do not have to complete this part to receive free and reduced price meals.)
Yes, school officials may use the information provided on this application to determine my child( ren)' s eligibility for free textbooks,
workbooks, and other school supplies.
Do not fill out this part. This is for sponsor' s use only. Annual Income Conversion: WeeklyX 52, Every 2 Weeks X 26, Twice A Month X 24, MonthlyX 12
Categorically Eligibility:
-
or-
Income
Eligibility: Er/
Free Meals
Reduced Meals
enied:
Signature/ Stamp
Verification:
of
Approving Official
,(
44 .
LL
Reason:
r
Ja/'t.Ia_
bt!/
Date Approved
2 /-
1,5 Date Withdrawn
Date
Confirming Official' s Signature
Date
Follow- up Official' s Signature
WVDE- ADM- 121
Temporary Free: Time Period
Temporary Reduced: Time Period
Continue
on
Back"
5•
Free
Reduced- Price Meals Household Application for 2012- 2013— West Virginia Dept. of Education
and
USE BLACK OR DARK BLUE INK. PRINT NEATLY, COMPLETE ONE APPLCIATION PER HOUSEHOLD
Names of ALL Children in School, Center, or Camp
1.
First Name
Last Name
S
t \-\,
Date of Birth
Mark if
MM/DD/ YY
Foster
MI
School, Center, or Camp
Grade
rye r'1
I
I
I
I
2. SNAP/ TANF NUMBER
SNAP
TANF
If any member of your household receives SNAP or TANF, indicate which program and provide the 10-digit case#
If any, SKIP TO PART 5)
3. HOMELESS, MIGRANT, RUNAWAY
If the
applying for is homeless,
child you are
migrant, or
Homeless
runaway,
check
the appropriate box and
call your
county
contact at
Migrant Runaway
LJ
4. HOUSEHOLD MEMBERS AND GROSS INCOME FROM LAST MONTH
List each person in the household. For each person who receives income, write the amount received and fill in how often it is received.
Monthly
Name( Last, First)
List
everyone
Attach a
in the Household.
separate sheet
if
Earnings
Monthly
from Work
Monthly
Welfare,
Before Deductions)
Other
Social
Monthly
Income
Pensions, Retirement,
Alimony
needed.
Payments
from
Child Support,
Su
Check
if no
Income
Security
Srni
si-cm
5
PAY'
22"-LS
$
3 rrttl
fv) 1' k` h
'
e
a r1
Total Number
of
Lo
Persons in Household
Total
Monthly
Income Before Deductions$
14" 773 ,00
5. Signature and Social Security Number ( Adult must sign.)
An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list the last 4 digits of his or her
Social Security Number or mark the" I do not have a Social Security Number" box. ( See Privacy Act Statement on the back of this page)
I certify( promise) that all information on this application is true and that all income is reported. I understand that the school system may get federal funds based on the information I
give. I understand that school officials may verify( check) the information. I understand that if I purposely give false information, my children) may lose meal benefits, and I maybe
prosecuted.
Today' s Date
Last 4 Di its of Social Security Number
a
Vt/.-
/)
C• 2
"-"
D7" i ,?
***
Si nature
L
15a,
30-4- 56
ek-
=
iz3
6.
I do not have a Social Security Number
rap.Work Phone Number
Home Phone Number
Printed Name
Mailing
1* *
tt
1-- a.ruCity
Address
Children' s Race
and
Ethnicity-(
e(v(( tc.
U v
23 (4S
State
ZIP Code
You do not have to complete this part to receive free and reduced price meals.)
Mark one or more racial identities from this group:
American Indian
Asian
Black
or
or
White
Alaska Native
Native Hawaiian or Other Pacific Islander
African American
And mark one ethnic identity from this group:
Hispanic
or
Not Hispanic or Latino
Latino
7. Other Benefits -( You do not have to complete this part to receive free and reduced price meals.)
Yes, school officials may use the information provided on this application to determine my child( ren)' s eligibility for free textbooks,
workbooks, and other school supplies.
Do not fill out this part. This is for Sponsor' s use only. Annual Income Conversion: WeeklyX 52, Every 2 Weeks X 26, Twice A Month X 24, MonthlyX 12
Categorically Eligibility:
-
Or-
Income
Eligibility: br
Free Meals
Reduced Meals
i
Temporary Free: Time Period
Temporary Reduced: Time Period
Denied; Reason:
n
Signature/ Stamp
Verification:
of
Approving Official `- ,
Confirming
•
lje GL
ret,_
f
4./'' '
Date Approved
Date Withdrawn
Date
Official' s Signature
Date
Follow- up Official' s Signature
WVDE- ADM- 121
a- 7- 13
Continue
on
Back"
tip•
Free
and
Reduced- Price Meals Household Application for 2012- 2013— West Virginia Dept. of Education
USE BLACK OR DARK BLUE INK, PRINT NEATLY. COMPLETE ONE APPLCIATION PER HOUSEHOLD
1. Names of ALL Children in School, Center, or Camp
First Name
Last Name
Date of Birth
Mark if
MM/DD/ YY
Foster
Ml _
Grade
School, Center, or Camp
Sara.IN
SMt-
I
SNAP/ TANF NUMBER
2
If anyany
SNAP
P
household receives SNAP
member of your
or
TANF, indicate
which program and provide
the 10- digit
T4NF
1
case#
If any, SKIP TO PART 5)
HOMELESS, MIGRANT, RUNAWAY
3.
If the
child you are
applying for is homeless,
migrant, or
S4
Z 3
Homeless Migrant Runaway
runaway,
check
the
appropriate
box
and call your
county
contact at
LJ
4. HOUSEHOLD MEMBERS AND GROSS INCOME FROM LAST MONTH
List each person in the household. For each person who receives income, write the amount received and fill in how often it is received.
Name( Last,
List
everyone
Attach
Monthly Earnings
Firstl
a separate sheet
rr,
if
Monthly
from Work
Before Deductions)
in the Household.
2ooa
Si - - 1 -,
Other
Social
Monthly
Income
Check
if no
Income
Security
$
tea
lfr•iay
Payments
from
Pensions, Retirement,
Alimony
needed.
1- 1
Monthly
Welfare,
Child Support,
$
r
Total Number
of
H
Persons in Household
Total
Monthly
Income Before Deductions$
y 06
5. Signature and Social Security Number ( Adult must sign.)
An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list the last 4 digits of his or her
Social Security Number or mark the" I do not have a Social Security Number" box. ( See Privacy Act Statement on the back of this page)
I certify( promise) that all information on this application is true and that all income is reported. I understand that the school system may get federal funds based on the information I
give. I understand that school officials may verify( check) the information. I understand that if! purposely give false information, my child(ran) may lose meal benefits, and I may be
Toda ' s Date
Last 4 Di its of Social Security Number
prosecuted.
sf
b zl0'
Signature
S re, i-E- h
LI 5 as
123 Ha ppl
6.
I do not have a Social Security Number
Work Phone Number
er
yl"....
City
and
4i
Soy - 55S- 121' 1--
Address
Children' s Race
I 3. 3
* * ** *
Home Phone Num
Printed Name
Mailing
I 3
Ethnicity-(
p
fw u
1
t‘1, G
MI y S
State
ZIP Code
You do not have to complete this part to receive free and reduced price meals.)
Mark one or more racial identities from this group:
American Indian
Asian
Black
or
African American
or
White
Alaska Native
Native Hawaiian or Other Pacific Islander
And mark one ethnic identity from this group:
Hispanic
or
Latino
Not Hispanic or Latino
7. Other Benefits -( You do not have to complete this part to receive free and reduced price meals.)
Yes, school officials may use the information provided on this application to determine my child( ren)' s eligibility for free textbooks,
workbooks, and other school supplies.
Do not fill out this part. This is for sponsor' s use only. Annual Income Conversion: WeeklyX 52. Every 2 Weeks X 26, Twice A Month X 24. MonthlyX 12
Categorically Eligibility:
-
Or-
Income
Free Meals
Eligibility:
Reduced Meals
Denied:
Signature/ Stamp
Verification:
of
Approving Official
Confirming
C
r
O,, (
GtAt
Reason:
z4- G" t--
Official' s Signature
Date Approved
2-,- 05'ate Withdrawn
Date
Follow- up Official' s Signature
WVDE- ADM- 121
Temporary Free: Time Period
Temporary Reduced: Time Period
Date
Continue
on
Back"
Free
Reduced- Price Meals Household Application for 2012- 2013— West Virginia Dept. of Education
and
USE BLACK OR DARK BLUE INK. PRINT NEATLY. COMPLETE ONE APPLCIATION PER HOUSEHOLD
1.
Names of ALL Children in School, Center, or Camp
Date
Mark if
Birth
Foster
School, Center, or Camp
Grade
4,
lSrP11 4
f 4L-Y
Ate,
N'
of
MM/DD/ YY
MI
First Name
Last Name
13
I
I
I
I
I
I
2. SNAP/ TANF NUMBER
SNAP
TANF
If any member of your household receives SNAP or TANF, indicate which program and provide the 10-digit case#
If any, SKIP TO PART 5)
HOMELESS, MIGRANT, RUNAWAY
3.
If the
applying for is homeless,
child you are
migrant, or
Homeless
runaway,
check
the
box and
appropriate
call your
county
contact at
Migrant Runaway
LJ
4. HOUSEHOLD MEMBERS AND GROSS INCOME FROM LAST MONTH
List each person in the household. For each person who receives income, write the amount received and fill in how often it is received.
Monthly
Name( Last, First)
List
everyone
Attach
in the Household.
a separate sheet
fM
5
Payments
Other
from
Child Support,
Su
ort,
Before Deductions)
if needed.
Monthly
Monthly Welfare,
Earnings
from Work
Alimony
Social
Monthly
Income
Pensions, Retirement
Check
if no
Income
Security
IS LO
1770
rr tkt-
r;atn 5 pm 'kk^
Total Number
of Persons
y
in Household
Total
Monthly
Income Before Deductions$
3S / D
5. Signature and Social Security Number ( Adult must sign.)
An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list the last 4 digits of his or her
Social Security Number or mark the" I do not have a Social Security Number" box. ( See Privacy Act Statement on the back of this page)
I certify( promise) that all information on this application is true and that all income is reported. 1 understand that the school system may get federal funds based on the information I
give. I understand that school officials may verify( check) the information. I understand that if I purposely give false information, my child(ren) may lose meal benefits, and I may be
Toda ' s Date
prosec
d.
Last 4 Di its of Social Security Number
4
vf/, 7C
'
O
Vi
0}
I 3
*****
1 2 2 'f
I do not have a Social Security Number
Signature
4.,
j15a, anv:-L-
301f-
I 23
Mailing
6.
Work Phone Number
L4r1,t,
apP
Address
Children'
SS'S -/ 2/ 2
Home Phone Number
Printed Name
s
Race
PPYPI<
14-
State
City
and
Ethnicity-(
j
w_
231-
l5
ZIP Code
You do not have to complete this part to receive free and reduced price meals.)
Mark one or more racial identities from this group:
American Indian
Asian
Black
or
or
White
Alaska Native
Native Hawaiian or Other Pacific Islander
African American
And mark one ethnic identity from this group:
Hispanic
or
Not Hispanic or Latino
Latino
7. Other Benefits -( You do not have to complete this part to receive free and reduced price meals.)
Yes, school officials may use the information provided on this application to determine my child( ren)' s eligibility for free textbooks,
workbooks, and other school supplies.
Do not fill out this part. This is for sponsor' s use only. Annual Income Conversion: WeeklyX 52, Every 2 Weeks X 26, Twice A Month X 24. MonthlyX 12
Categorically Eligibility:
-
or-
Income
Eligibili
NI
Free Meals
Reduced Meals
Temporary Free: Time Period
Temporary Reduced: Time Period
Denied: Reason:
Signature/ Stamp
Verification:
of
Approving Official
Confirming
C
I-•
ot
/ U ._ P
1
hc'C1( Jl
2
2,Date Withdrawn
Date
Official' s Signature
Date
Follow- up Official' s Signature
WVDE- ADM- 121
Date Approved
Continue
on
Back"
g
Free
Reduced- Price Meals Household Application for 2011- 2012— West Virginia Dept. of Education
and
USE BLACK OR DARK BLUE INK. PRINT NEATLY, COMPLETE ONE APPLCIA T/ON PER HOUSEHOLD
1.
Names of ALL Children in School, Center, or Camp
Date
Last Name
510.1
First Name
144
54r&
h
i 44
e)rirl
j
of
Mark if
Birth
Foster
MM/DD/ YY
MI
I
School, Center, or Camp
Grade
/
I
I
I
I
I
I
2. SNAP/ TANF NUMBER
SNAP
TANF
If any member of your household receives SNAP or TANF. indicate which program and provide the 10- digit case#
If any, SKIP TO PART 5)
3.
HOMELESS, MIGRANT, RUNAWAY
If the
4.
applying for
child you are
homeless,
is
migrant, or
Homeless
runaway,
the appropriate box and call
check
your
county
Migrant
contact at
Runaway
LJ
HOUSEHOLD MEMBERS AND GROSS INCOME FROM LAST MONTH
List each person in the household.
For each person who receives income, write the amount received and fill in how often it is received.
Monthly
Name( Last, First)
List
everyone
Attach
a separate sheet
Set,
3-
5r
u r,
7n
I ,-
Other
Social
Check
Monthly
Income
Pensions, Retirement,
Alimony
if no
Income
Security
$
Ibin0
r-,
Payments
from
Child Support,
needed.
LIaa. Sr ,t-
Monthly
Monthly Welfare,
Before Deductions)
if
hnI- -h
ory
Earnings
from Work
in the Household.
$
r,
l-
f
Total Number
of
Persons in Household
Total
Monthly
Income Before Deductions$
2:'
o
5. Signature and Social Security Number ( Adult must sign.)
An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list the last 4 digits of his or her
Social Security Number or mark the" I do not have a Social Security Number" box. ( See Privacy Act Statement on the back of this page)
I certify( promise) that all information on this application is true and that all income is reported. I understand that the school system may get federal funds based on the information I
give. 1 understand that school officials may verify( check) the information. I understand that if I purposely give false information, my child(ren) may lose meal benefits, and I may be
Toda '
prosecu
1'
C.`
r
L_R' i\.
s
Date
7
Last 4 Di its of Social Security Number
1
1
I
2v `1
I do not have a Social Security Number
Signature
LI
SM I ---
-
N.
h
7N.! -r-_.r
Printed Name
Mailing
6.
Home Phone Number
Address
Children'
t7, 7
-
Work Phone Number
State
City
s
Race
and
Ethnicity -(
ZIP Code
You do not have to complete this part to receive free and reduced price meals.)
Mark one or more racial identities from this group:
Asian
Black
American Indian
or
White
or Alaska Native
Native Hawaiian or Other Pacific Islander
African American
And mark one ethnic identity from this group:
Hispanic
7.
or
Latino
Not Hispanic or Latino
Other Benefits-( You do not have to complete this part to receive free and reduced price meals.)
Yes, school officials may use the information provided on this application to determine my child( ren)' s eligibility for free textbooks.
workbooks. and other school supplies.
Do not fill out this part. This is for sponsor' s use only. Annual Income Conversion: WeeklyX 52, Every 2 Weeks X 26, Twice A Month X 24, MonthlyX 12
Categorically Eligibility:
or-
-
Income Eligib ility:
V
Free Meals
Reduced Meals
D'enieed:
Signature/ Stamp
Verification:
of
Approving
Official
Confirming
lJ "LC
t h{ JLL
Reason:
f' LL"
V"`
Official' s Signature
Date Approved
2-
2
1^ I "
Date Withdrawn
Date
Follow- up Official' s Signature
WVDE- ADM- 121
Temporary Free: Time Period
Temporary Reduced: Time Period
Date
Continue
on
Back"
GUIDELINES TO DETERMINE PARTICIPANT ELIGIBILITY
FOR FREE AND REDUCED PRICE MEALS
School Year 2012-2013
ANNUAL FAMILY INCOME BEFORE DEDUCTIONS
ELIGIBLE FOR FREE MEALS OR FREE MILK
FAMILY
SIZE
YEARLY
MONTHLY
TWICE PER
EVERY TWO
MONTH
WEEKS
ELIGIBLE FOR REDUCED PRICE MEALS
WEEKLY
YEARLY
MONTHLY
TWICE PER
EVERY TWO
MONTH
WEEKS
WEEKLY
ONE
$14,521
$1,211
$606
$559
$280
$20,665
$1,723
$862
$795
$398
TWO
19,669
1,640
820
757
379
27,991
2,333
1,167
1,077
539
THREE
24,817
2,069
1,035
955
478
35,317
2,944
1,472
1,359
680
FOUR
29,965
2,498
1,249
1,153
577
42,643
3,554
1,777
1,641
821
FIVE
35,113
2,927
1,464
1,351
676
49,969
4,165
2,083
1,922
961
SIX
40,261
3,356
1,678
1,549
775
57,295
4,775
2,388
2,204
1,102
SEVEN
45,409
3,785
1,893
1,747
874
64,621
5,386
2,693
2,486
1,243
EIGHT
50,557
4,214
2,107
1,945
973
71,947
5,996
2,998
2,768
1,384
7,326
611
306
282
141
FOR EACH ADDITIONAL FAMILY MEMBER, ADD
5,148
429
215
198
99
CONVERSION FACTOR
Annual Income Conversion: Weekly X 52, Every 2 Weeks X 26, Twice A Month X 24, Monthly X 12
IncomeEligibilityGuidelines