(School or County Letterhead)
PARENT LETTER
DIFFERENCE BETWEEN INCOME DOCUMENTATION AND APPLICATION
Date
Dear
:
We have reviewed the document(s) submitted as proof of income. The proof
checked below does NOT agree with the information on your application for free or
reduced price meals.
FOOD STAMP ELIGIBILITY
Wrong family
Not current for this school year
Other
PAYCHECK STUB, PAY ENVELOPE, LETTER FROM EMPLOYER, SELF EMPLOYED
PROOF OF INCOME
Income reported for wrong time period
Income reported higher than on application
Income reported lower than on application
Other
BENEFIT NOTICES OR AGENCY RECORDS FROM ________________________
Not current for the school year
Income reported higher than on application
Income reported lower than on application
Other
WVDE-ADM-23
2004
0210tdr/POOMEX
Parent Letter
Difference Between Income
Documentation and Application
Page 2
WRITTEN STATEMENT EXPLAINING NO HOUSEHOLD INCOME
Statement shows that there is income
Statement does not fully explain household conditions
Other
As a result of this difference, unless you can provide adequate proof of eligibility within
ten (10) days (by
) or submit a new application (enclosed),
benefits to your child will:
Change from reduced price meals to free
This change will occur only if you contact the school by the date listed above
to explain the difference.
Change from free meals to reduced priced meals at $
and $
for breakfast.
for lunch
Be stopped.
This change will remain in effect until you provide the information required. If you have
any other proof to submit, please send it to the school and this decision will be
reconsidered. Failure to reply within ten (10) days will result in the change noted above.
You may reapply at any time during the school year if your eligibility circumstances
changes.
If you do not agree with this decision you may request a hearing by contacting
(hearing officer) at
(county office).
If you request a hearing, your child will continue to receive free or reduced price meals
until the decision of the hearing official is made.
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 of discrimination, write USDA, Director, Office of Civil Rights, 1400
Independence Avenue, SW, Washington, DC, 20250-9410, or call toll free (866) 6329992 (Voice). TDD users can contact the USDA through local relay or the Federal
Relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice users). USDA is an
equal opportunity provider and employer.
You have ten (10) days from the date of this letter to request such a hearing.
Sincerely,
School Principal
WVDE-ADM-23
2004
0210tdr/POOMEX