Portal

CEP Income Eligibility Form

Date Withdrew

F R D

Attachment Va

To apply for free and reduced price meals for your children, complete only one form for your household, sign your name and hit the submit button. Call 315-689-8500, extension 5002, if you need help.

2. SNAP/TANF/FDPIR Benefits:

Name:

Case #:

All Household Members (including yourself and all children that have income).

List all Household members not listed in Step 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total income for each source in whole dollars only. If they do not receive income from any other source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.

A	B Amount	C How Often	D Amount	E How Often	F Amount	G How Often	H Amount	I How Often	J

Total Household Members (Children / Adults)*

*Last Four Digits of Social Security Number:

4.Signature: An adult household member must sign this application before it can be approved.

I certify (promise) that all 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.

Sign with mouse

Date

Hispanic or Latino Not Hispanic or Latino

Ethnicity:

Race:

School Year*

First

Last

If anyone in your household receives either SNAP. TANF, or FDPIR benefits, list their name and case# below. Skip to Part 4, and sign the application..

I do not have a SS#

Name of Household Member

Earnings from work before deductions

Child Support and/or Alimony

Pensions, Retirement Payments

Other Income, Social Security

No Income

8. Ethnicity and Race are optional: responding to this section does not effect your child's eligibility.

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

Student Name

School

Grade / Teacher

Foster Child

Homeless, Migrant, or Runaway

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 (biweekly) X 26; Twice Per month X24; Monthly X12

SNAP/TANF/Foster

Income Household:

Free Meals Reduced Price Meals Denied/Paid

Date

Total Household Income/How Often:

Household Size:

Email Address:

Home Phone:

Work Phone:

Home Address:

Yes No

Approval by Asst. Superintendent

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410; or

(2) fax: (833) 256-1665 or (202) 690-7442; or

(3) email: program.intake@usda.gov.

This institution is an equal opportunity provider.