Roxbury Township Public Schools

Food & Nutrition Department

One Bryant Drive

Succasunna, N.J. 07876

973 584 2320 fax 973 584 2896

www.roxbury,org/foodservices

Marilyn McSpiritt MS RD

Director Food & Nutrition

mmcspiritt@roxbury.org

Privacy Act Statement: This explains how we will use the information you give us.

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 social security number of the adult household member who signs the application. The social security number is not required when you apply on behalf of a foster child or you list a Food Stamp Program, 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.

Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. In accordance with Federal law and U.S. Department of Agriculture 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 to USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington DC 20250-94 10 or call 202-720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

Application #

One Application per Household Effective July 1, 2005

FREE AND REDUCED PRICE SCHOOL MEALS HOUSEHOLD APPLICATION

Part 1. Children in School (Use a separate application for each foster child)

Names of all children in school (First, Middle initial last )	School name	Grade	Food Stamps or TANF case # (if any ) Skip to PART 5 If you list a Food Stamp or TANF #

Part 2. If the child you are applying for is homeless, migrant, or a runaway check the appropriate box and call [your school, homeless liaison, migrant coordinator at phone #

Homeless Migrant Runaway

Part 3. Foster Child

If this application is for a child who is the legal responsibility of a welfare agency or court, check this box and then list the amount of the child's personal use monthly income: $__________. Skip to Part 5.

Part 4. Total Household Gross Income-You must tell us how much and how often

NAME	Gross Income and how often it was received Example $100./monthly/$100. twice a month/ $100. every other week/$100 weekly				Check if
(List everyone in household)	Earnings from work Before Deductions	Welfare, Child support Alimony	Pension, Retirement Social Security	All other income	NO income
	$______/______	$______/________	$______/________	$______/_______
	$______/______	$______/________	$______/________	$______/_______
	$______/______	$______/________	$______/________	$______/_______
	$______/______	$______/________	$______/________	$______/_______
	$______/______	$______/________	$______/________	$______/_______
	$______/_______	$______/________	$______/________	$______/_______
	$______/_______	$______/________	$______/________	$______/______
	$______/_______	$______/________	$______/________	$______/_______

Part 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 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 schoolwill get Federal funds based on the information I give. I understand that school officials may verify (check) the information. Iunderstand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted.

Sign here: X______________________________Print name:_____________________Date:________

Address:_______________________________________________________Phone Number:_____________________

Social Security Number: __ __ __ - __ __ - __ __ __ __ I do not have a Social Security Number

Part 6. Children's racial and ethnic identities (optional)

Mark one or more racial identities: Mark one ethnic identity:

Asian American Indian or Alaska Native Hispanic or Latino

White Native Hawaiian or Other Pacific Islander Not Hispanic or Latino

Black or African American Other

Don't 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 Twice A Month, Month, Year

Total Income: ____________ Per: Week, Every 2 Weeks, Household size: ________

Categorical Eligibility: ___ Date Withdrawn: ________Eligibility: Free___ Reduced___ Denied___ Reason:

Temporary: Free_____ Reduced_____ Time Period: ___________ (expires after _____ days)

Determining Official's Signature: ______________________________ Date: ______________

Confirming Official's Signature: __________________ Date: _______ Follow-up Official's Signature: __________________ Date: