Application For Free and Reduced-Price Meals - Confidential

PARENT OR GUARDIAN: To apply for free or reduced-price meals for your child, you must complete this application.
You must sign this form and return it to your child's school.

If you need help, call your child's school. Additional instructions are on the back of this application. (Use a separate 
form for each student.)

A. STUDENT'S NAME ________________________________________________________ Grade ____________
                                                          (Last) (First) (Middle)

Room Number _____________ School ________________________

Birthdate _________/_________/_________
                (Month)        (Day)         (Year)

Foster child Income $______________   Food Stamp/CalWORKs Eligible/FDPIR

B. CalWORKs, FDPIR or FOOD STAMP HOUSEHOLDS: If your household is now receiving CalWORKs,
FDPIR or Food Stamps, please give your case number and skip Section C.

Food Stamp Case # ______________________ CalWORKs Case # _____________________

FDPIR Case # _____________________

C. INCOME HOUSEHOLDS: Income Received Last Month By All Household Members

List all Household Members and Income received

Name of All Household Members (include Child Listed Above

 School Student Attends Age of Children Under
21 		Monthly Earnings From All Jobs
Before Deductions 		Monthly Social Security/
Pension/
Retirement/
Disability 		Monthly Welfare (CalWORKS) Child
Support/
Alimony 		All Other Monthly Income Received Total Monthly Income
1                                                       $                 $                  $                    $                  $                
2     $ $ $ $ $
3     $ $ $ $ $
4     $ $ $ $ $
5     $ $ $ $ $
6     $ $ $ $ $
7     $ $ $ $ $
8     $ $ $ $ $
 
D. I CERTIFY that all the information given on this form is true and correct, and that all income is listed. I understand that I am asking for federal aid. I may be asked to prove the information given, and if I knowingly give incorrect information, I may be prosecuted under state and federal laws.

SIGNATURE of PARENT, GUARDIAN, OR ADULT HOUSEHOLD MEMBER:

 FOR SCHOOL USE ONLY:

Total Number of Household Members               

Total Household Monthly Income    $                

 
_________________________________  ________________  ______________________  _______________
Name (Signature)                                       Date Signed          Telephone (during day)               SSN

_________________________________________________________________________________________
Home Address                                                                     City                           State           Zip