Date Withdrew__________ Attachment Va F ____R _____D_____

2013-2014 Application for Free and Reduced Price School Meals/Milk

To apply for free and reduced price meals for your children, read the instructions on the back, complete only one form for your household, sign your name and
return it to the school your child attends. Call (518) 475-6645 if you need help. Additional names may be listed on a separate paper.

1. List all children in your household who attend school:

Student Name School Grade/Teacher Foster Child

No Income









2. SNAP or TANF Benefits:
If anyone in your household receives either SNAP, TANF or FDPIR benefits, list their name and CASE # here. Skip to Part 5, and sign the application.

Name:______________________________________ CASE #__________________________________


3. If any child you are applying for is homeless, migrant or a runaway, please call this number: ________________________________________________
Homeless Migrant Runaway (Homeless Liaison/Migrant Education Coordinator)


4. Household Gross Income: List all people living in your household, how much and how often they are paid (weekly, every other week, twice per month,
monthly). Do not leave income blank. If no income, check box. If you have listed a foster child above, you must report their personal income.

Name of household member Earnings from work
before deductions
Amount / How Often
Child Support, Alimony

Amount / How Often
Pensions, Retirement
Payments
Amount / How Often
Other Income, Social
Security
Amount / How Often
No
Income

$ ________ / ________ $ ________ / ________ $ ________ / ________ $ ________ / ________

$ ________ / ________ $ ________ / ________ $ ________ / ________ $ ________ / ________

$ ________ / ________ $ ________ / ________ $ ________ / ________ $ ________ / ________

$ ________ / ________ $ ________ / ________ $ ________ / ________ $ ________ / ________

$ ________ / ________ $ ________ / ________ $ ________ / ________ $ ________ / ________

$ ________ / ________ $ ________ / ________ $ ________ / ________ $ ________ / ________

$ ________ / ________ $ ________ / ________ $ ________ / ________ $ ________ / ________

$ ________ / ________ $ ________ / ________ $ ________ / ________ $ ________ / ________

$ ________ / ________ $ ________ / ________ $ ________ / ________ $ ________ / ________



5. Signature: An adult household member must sign this application and provide the last four digits of their Social Security Number (SS#), or mark the I do not
have a SS# box before it can be approved.
I certify (promise) that all of the information on this application is true and that all income is reported. I understand that the information is being given so the school
will get federal funds; the school officials may verify the information and if I purposely give false information, I may be prosecuted under applicable State and
federal laws, and my children may lose meal benefits.
Signature:__________________________________________________ Date: ___________________

Email Address: ______________________________________________ Last Four Digits of Social Security Number: ***-**- __ __ __ __

Home Phone _________________ Work Phone_____________________ Home Address______________________________________________




DO NOT WRITE BELOW THIS LINE FOR SCHOOL USE ONLY
Annual Income Conversion (Only convert when multiple income frequencies are reported on application)
Weekly X 52; Every Two Weeks (bi-weekly) X 26; Twice Per Month X 24; Monthly X 12

SNAP/TANF/Foster
Income Household: Total Household Income/How Often: _________________/________________ Household Size: _________________
Free Meals Reduced Price Meals Denied/Paid
Signature of Reviewing Official________________________________________________________ Date Notice Sent:________________
I do not
have a
SS#
APPLICATION INSTRUCTIONS

To apply for free and reduced price meals, submit a Free Meals/Milk Eligibility Letter received from the Office of Temporary and Disability Assistance
OR complete only one application for your household using the instructions.. Sign the application and return the application to your child(ren)s school.
If you have a foster child in your household, you may include them on your application. A separate application is no longer needed. Ensure that all
information is provided. Failure to do so may result in denial of benefits for your child or unnecessary delay in approving your application.

PART 1 ALL HOUSEHOLDS MUST COMPLETE STUDENT INFORMATION. DO NOT FILL OUT MORE THAN ONE APPLICATION
FOR YOUR HOUSEHOLD.
(1) Print the names of the children, including foster children, for whom you are applying on one application.
(2) List their grade and school.
(3) Check the box to indicate a foster child living in your household, and check the box for each child with no income.

PART 2 HOUSEHOLDS GETTING SNAP, TANF OR FDPIR SHOULD COMPLETE PART 2 AND SIGN PART 5.
(1) List a current SNAP, TANF or FDPIR (Food Distribution Program on Indian Reservations) case number of anyone living in
your household. Do not use the 16-digit number on your benefit card. The case number is provided on your benefit letter.
(2) An adult household member must sign the application in PART 5. SKIP PART 4. Do not list names of household members
or income if you list a SNAP, TANF or FDPIR case number.

PART 3 Before completing an application for a child who may be homeless, a migrant education student, or a runaway,
please call your schools homeless liaison or migrant education coordinator at this number:
__________________________________________________________________
(Homeless Liaison/Migrant Education Coordinator name and Phone Number)

PARTS 4 & 5 ALL OTHER HOUSEHOLDS MUST COMPLETE THESE PARTS AND ALL OF PART 5.
(1) Write the names of everyone in your household, whether or not they get income. Include yourself, the children you are
applying for, all other children, your spouse, grandparents, and other related and unrelated people in your household. Use
another piece of paper if you need more space.
(2) Write the amount of current income each household member receives, before taxes or anything else is taken out, and
indicate where it came from, such as earnings, welfare, pensions and other income. If the current income was more or less
than usual, write that persons usual income. Specify how often this income amount is received: weekly, every other
week (bi-weekly), 2 x per month, monthly. If no income, check the box. The value of any child care provided or
arranged, or any amount received as payment for such child care or reimbursement for costs incurred for such care under
the Child Care and Development Block Grant, TANF and At Risk Child Care Programs should not be considered as income
for this program.
(3) The application must include the last four digits only of the social security number of the adult who signs PART 5 if Part 4 is
completed. If the adult does not have a social security number, check the box. If you listed a SNAP, TANF or FDPIR
number, a social security number is not needed.


OTHER BENEFITS: Your child may be eligible for benefits such as Medicaid or Childrens Health Insurance Program (CHIP). In order to determine if your child is eligible, program
officials need information from your free and reduced price meal application. Your written consent is required before any information may be released. Please refer to the attached parent
Disclosure Letter and Consent Statement for information about other benefits.

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 last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security
number are not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), 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.

DISCRIMINATION COMPLAINTS
The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability,
sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from
any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited basis will apply to all
programs and/or employment activities.)

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form (PDF), found online at
http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in
the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C.
20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov

Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint please contact USDA through the Federal Relay Service at (800) 877-
8339 or (800) 845-6136 or email at program.intake@usda.gov.

USDA is an equal opportunity provider and employer.



CITY SCHOOL DISTRICT OF ALBANY
FOOD SERVICE DEPARTMENT


Dear Parent/Guardian:

Children need healthy meals to learn. The City School District of Albany offers healthy meals every school day. Breakfast costs $1.50 per meal
and lunch costs $2.25 in the ELEMENTARY SCHOOLS and $2.50 in the MIDDLE and HIGH SCHOOLS. Your children may qualify for free meals
or for reduced price meals. Reduced price is $0.25 for breakfast and $0.25 for lunch.

1. Do I need to fill out an application for each child? No. Complete the application to apply for free or reduced price meals. Use one
Free and Reduced Price School Meals Application for all students in your household. We cannot approve an application that is not
complete, so be sure to fill out all required information. Return the completed application to your child(ren)s school
2. Who can get free meals? All children in households receiving benefits from SNAP, the Food Distribution Program on Indian
Reservations or TANF, can get free meals regardless of your income. Also, your children can get free meals if your households gross
income is within the free limits on the Federal Income Eligibility Guidelines.
3. Can foster children get free meals? Yes, foster children that are under the legal responsibility of a foster care agency or court, are
eligible for free meals. Any foster child in the household is eligible for free meals regardless of income.
4. Can homeless, runaway, and migrant children get free meals? Yes, children who meet the definition of homeless, runaway, or
migrant qualify for free meals. If you havent been told your children will get free meals, please call or e-mail the school, homeless liaison
or migrant coordinator to see if they qualify.
5. WHO CAN GET REDUCED PRICE MEALS? Your children can get low cost meals if your household income is within the reduced price
limits on the Federal Eligibility Income Chart, shown on this application.
6. SHOULD I FILL OUT AN APPLICATION IF I RECEIVED A LETTER THIS SCHOOL YEAR SAYING MY CHILDREN ARE APPROVED
FOR FREE MEALS? Please read the letter you got carefully and follow the instructions. Call the School District at (518) 475-6645 if you
have questions.
7. MY CHILDS APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT ANOTHER ONE? Yes. Your childs
application is only good for that school year and for the first few days of this school year. You must send in a new application unless the
school told you that your child is eligible for the new school year.
8. I GET WIC. CAN MY CHILD(REN) GET FREE MEALS? Children in households participating in WIC may be eligible for free or reduced
price meals. Please fill out a FREE/REDUCED PRICE MEAL application.
9. Will the information I give be checked? Yes and we may also ask you to send written proof.
10. If I dont qualify now, may I apply later? Yes, you may apply at any time during the school year. For example, children with a parent or
guardian who becomes unemployed may become eligible for free and reduced price meals if the household income drops below the
income limit.
11. What if I disagree with the schools decision about my application? You should talk to school officials. You also may ask for a
hearing by calling or writing to: Assi st ant Super i nt endent of Busi ness at t he Di st r i ct Admi ni st r at i on Bui l di ng,
Academy Par k, Al bany NY 12207, ( 518) 475 - 6020
12. May I apply if someone in my household is not a U.S. citizen? Yes. You or your child(ren) do not have to be U.S. citizens to
qualify for free or reduced price meals.
13. Who should I include as members of my household? You must include all people living in your household, related or not (such as
grandparents, other relatives, or friends) who share income and expenses. You must include yourself and all children living with you. If
you live with other people who are economically independent (for example, people who you do not support, who do not share income with
you or your children, and who pay a pro-rated share of expenses), do not include them.
14. What if my income is not always the same? List the amount that you normally receive. For example, if you normally make $1000
each month, but you missed some work last month and only made $900, put down that you made $1000 per month. If you normally get
overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced,
use your current income.
15. We are in the military. Do we include our housing allowance as income? If you get an off-base housing allowance, it must be
included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance
as income.
16. My spouse is deployed to a combat zone. Is her combat pay counted as income? No, if the combat pay is received in addition to
her basic pay because of her deployment and it wasnt received before she was deployed, combat pay is not counted as income. Contact
your school for more information.
17. My family needs more help. Are there other programs we might apply for? To find out how to apply for SNAP or other
assistance benefits, contact your local assistance office or call 1-800-342-3009.






2013-2014 INCOME ELIGIBILITY GUIDELINES
FOR FREE AND REDUCED PRICE MEALS OR FREE MILK

REDUCED PRICE ELIGIBILITY INCOME CHART


Total Family Size Annual Monthly Twice per
Month
Every Two
Weeks
Weekly
1 $ 21,257 $ 1,772 $ 886 $ 818 $ 409
2 $ 28,694 $ 2,392 $ 1,196 $ 1,104 $ 552
3 $ 36,131 $ 3,011 $ 1,506 $ 1,390 $ 695
4 $ 43,568 $ 3,631 $ 1,816 $ 1,676 $ 838
5 $ 51,005 $ 4,251 $ 2,126 $ 1,962 $ 981
6 $ 58,442 $ 4,871 $ 2,436 $ 2,248 $ 1,124
7 $ 65,879 $ 5,490 $ 2,745 $ 2,534 $ 1,267
8 $ 73,316 $ 6,110 $ 3,055 $ 2,820 $ 1,410
Each addl person
add.
$ 7,437 $ 620 $ 310 $ 287 $ 144

How to Apply: To get free or reduced price meals for your children you may submit an Eligibility Letter for Free Meals/Milk (formerly Direct
Certification Letter) received from the NYS Office of Temporary and Disability Assistance, OR carefully complete one application for your household and
return it to the designated office. If you now receive Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance to Needy Families
(TANF) for any children, or participate in the Food Distribution Program on Indian Reservations (FDPIR), the application must include the children's names,
the household SNAP, TANF or FDPIR case number and the signature of an adult household member. All children should be listed on the same
application. If you do not list a food stamp, TANF or FDPIR case number for all the children for whom you are applying, the application must include the
names of everyone in the household, the amount of income each household member, and how often it is received and where it comes from. It must
include the signature of an adult household member and the last four digits of that adult's social security number, or check the box if the adult does not
have a social security number. An application that is not complete cannot be approved. Contact your local Department of Social Services for your food
stamp or TANF case number or complete the income portion of the application.

Reporting Changes: The benefits that you are approved for at the time of application are effective for the entire school year. You no longer
need to report changes for an increase in income or decrease in household size, or if you no longer receive food stamps.

Income Exclusions: The value of any child care provided or arranged, or any amount received as payment for such child care or
reimbursement for costs incurred for such care under the Child Care Development (Block Grant) Fund should not be considered as income for this
program.

Nondiscrimination Statement: The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for
employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital
status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected
genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited basis will apply to all programs
and/or employment activities.)

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form (PDF), found online at
http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter
containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture,
Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at
program.intake@usda.gov.

Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint pl ease contact USDA through
the Federal Relay Service at (800) 877-8339 or (800) 845-6136.
USDA is an equal opportunity provider and employer.

Meal Service to Children With Disabilities: Federal regulations require schools and institutions to serve meals at no extra charge to children
with a disability which may restrict their diet. A student with a disability is defined in 7CFR Part 15b.3 of Federal regulations, as one who has a physical or
mental impairment which substantially limits one or more major life activities. Major life activities are defined to include functions such as caring for ones
self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working. You must request the special meals from the school
and provide the school with medical certification from a medical doctor. If you believe your child needs substitutions because of a disability, please get in
touch with us for further information, as there is specific information that the medical certification must contain.

Confidentiality: The United States Department of Agriculture has approved the release of students names and eligibility status, without parent/guardian
consent, to persons directly connected with the administration or enforcement of federal education programs such as Title I and the National Assessment
of Educational Progress (NAEP), which are United States Department of Education programs used to determine areas such as the allocation of funds to
schools, to evaluate socioeconomic status of the school's attendance area, and to assess educational progress. Information may also be released to
State health or State education programs administered by the State agency or local education agency, provided the State or local education agency
administers the program, and federal State or local nutrition programs similar to the National School Lunch Program. Additionally, all information
contained in the free and reduced price application may be released to persons directly connected with the administration or enforcement of programs
authorized under the National School Lunch Act (NSLA) or Child Nutrition Act (CNA); including the National School Lunch and School Breakfast Programs,
the Special Milk Program, the Child and Adult Care Food Program, Summer Food Service Program and the Special Supplemental Nutrition Program for
Women Infants and Children (WIC); the Comptroller General of the United States for audit purposes, and federal, State or local law enforcement officials
investigating alleged violation of the programs under the NSLA or CNA.

The disclosure of eligibility information not specifically authorized by the NSLA requires a written consent statement from the parent/guardian.
We will let you know when your application is approved or denied.


Sincerely,
Food Service Administration
City School District of Albany
(518) 475-6645