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Letter to Household
Golden Valley Unified School District
Enter all household members who are infants, children, and students up to and including grade 12.
Definition of Household Member: Anyone who is living with you and shares income and expenses, even if not related. Children in Foster care and children who meet the definition of Homeless, Migrant, or Runaway are eligible for free meals. Read How to Apply for Free and Reduced Price School Meals for more information.
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.
Child Household Members
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.
List all Household Members not listed in the previous step (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total gross income (before taxes) for each source in whole dollars (no cents) only. If they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.

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.
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 is 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.
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.
First Name
Last Name
We are required to ask for information about your children's race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children's eligibility for free or reduced price meals or Summer EBT.
Race (Choose one or more regardless of ethnicity)

Applicant Information
Address
Phone
Email
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.
Child Household Members
Total Child Income:

Frequency:
Adult Household Members
Signature
SSN :
Signed By:
Review and Submit
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.
Thank you for completing the Universal Benefit Application. We'll notify you if your household has qualifying students that may be eligible for district, local, state, or federal program benefits. If you have any questions about the form, please contact Bertha Vargas, Director of Special Programs, at 559-645-3570 or by mail at 37479 Ave 12, Madera, CA 93636, c/o Special Programs.