Select State
If any Household Members (including you) currently participate in one or more of the following assistance programs, please select and enter a case number.
Do not include income earned by adults in your household. This will be entered on the next step.
Sometimes children in the household earn income. Please enter the total income earned by the household members listed below.
Please enter any income earned by:
Are you unsure what to include here? Review the charts titled "Sources of Income" for more information. The "Sources of Income for Children" chart will help you with the Child Income section. The "Sources of Income for Adults" chart will help you with the All Adults Household Members section.
I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits and I may be prosecuted under applicable State and Federal laws.
Applicant Information
Tell us how many infants, children, school students and adults live in your household. They do NOT have to be related to you to be part of your household.
Total Child Income:
Frequency:
Signature
Please review the information and verify that it is correct. Make any modifications necessary by using the pencil next to each section.
I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits and I may be prosecuted under applicable State and Federal laws.