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June 2023 2023-24 Application for Free and Reduced-price School Meals Return to Jack Jackter Intermediate School
Page 1 Complete one application per household. Please use a pen (not a pencil). Application No: ______________
List ALL children who are infants and students up to and including grade 12. If more spaces are required for additional names, attach another page.
STEP 1
sheet of paper.)
Student?
Definition of Household
Child’s First Name MI Child’s Last Name School Grade Yes No Foster Head Homeless or
Start Runaway
Member: “Anyone who is
living with you and shares
Check all that apply
income and expenses,
even if not related.”
Children in Foster care
and children who meet the
definition of Homeless or
Runaway are eligible for
free meals. Read How to
Apply for Free or
Reduced-price School
Meals for more information.
Do any household members (including you) currently participate in one or more of the following Assistance Programs – SNAP or TFA? (This does NOT include
STEP 2
medical (HUSKY) benefits).
If NO, > Go to STEP 3 If YES, a household member does participate in SNAP or TFA, write a SNAP OR TFA case number here and then go to STEP 4 (Do not Case Number: (Not an EBT Number):
complete STEP 3.) To quicken the approval process, it is strongly recommended that you submit proof of SNAP or TFA eligibility with
this application. See instructions. Write only one case number in this space.
Report Income for ALL Household Members (Skip this step if you answered “Yes” to Step 2)
STEP 3
How often?
Are you unsure what
A. Child Income Child income Weekly Bi-Weekly 2x Month Monthly Annual
income to include Sometimes children in the household earn income. Please include the TOTAL gross income (before taxes and
here? deductions) earned by all Child Household Members listed in STEP 1 here. $
Flip the page and B. All Adult Household Members (Anyone who is living with you and shares income and expenses, even if not related, including you.)
review the charts titled
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 gross income (before taxes and deductions)
“Sources of Income” for
more information.
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.
How often received? How often? How often received? Pensions/Retirement, SS, SSI, How often received?
Name of Adult Household Members Public Assistance/
The “Sources of Earnings from Work VA benefits, All other income Weekly Bi-Weekly 2x Month Monthly Annual
(First & Last Name) Weekly Bi-Weekly 2x Month Monthly Annual Child Support/Alimony Weekly Bi-Weekly 2x Month Monthly Annual
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 Adult
Household Members $ $ $ $ $
section.
$ $ $ $
Note: Biweekly is Every
2 Weeks
Total Household Members
Last Four Digits of Social Security Number of Primary
(Children and Adults –
Wage Earner or Other Adult Household Member
X X X X X Check if no social security number ☐
Step 1 & Step 3)
STEP 4 Contact
Contact Information
informationand
andAdult signature Return completed form to your child’s school or JJIS Attn; Café 215 Halls Hill Rd, Colchester CT 06415
adultSignature.
“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.”
Printed Name of Adult Signing the Form Signature of Adult Today’s Date
Mailing Address (if available) Apt # Town or City State Zip Daytime Phone and Email (optional)
June 2023
Page 2
2023-24 Application for Free and Reduced-price School Meals
Sources of Income
Earnings from Work Public Assistance/Alimony/ Pensions/Retirement/ Examples of Income for Children
Child Support All other sources of income
• Salary, wages, cash bonuses, tips, • Unemployment benefits • Social Security/Disability (including railroad • A child has a regular full or part-time job where they earn a salary or wages
commissions • Workers’ compensation retirement and black lung benefits)
• Net income from self-employment (farm or • Supplemental Security Income (SSI) • Private Pensions or disability benefits • A child is blind or disabled and receives Social Security benefits
business) • Cash assistance from State or local • Income from trusts or estates
• A parent is disabled, retired, or deceased, and their child receives Social Security benefits
If you are in the U.S. Military: government • Annuities
• Alimony payments • Investment income • A friend or extended family member regularly gives a child spending money
• Basic pay and cash bonuses (do NOT include
• Child support payments • Earned interest
combat pay, FSSA, or privatized housing
• Veterans’ benefits • Rental income • A child receives regular income from a private pension fund, annuity, or trust
allowances)
• Strike benefits • Regular cash payments from outside household
• Allowances for off-base housing, food,
and clothing
OPTIONAL Children’s Racial and Ethnic Identities. This information is kept confidential and may be protected by the Privacy Act of 1974.
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.
Ethnicity (check one): ❑ Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin, regardless of race) ❑ Not Hispanic or Latino
Race (check one or more): ❑ American Indian or Alaskan Native ❑ Asian ❑ Black or African American ❑ Native Hawaiian or Other Pacific Islander ❑ White
School Use Only – Do Not Write Below This Line
The Determining Official (DO) for the school/district MUST complete this section. (Only convert to annual income if there are different frequencies of income listed in Step 3.)
Annual Income Conversion: Weekly X 52 ◆ Every 2 weeks X 26 ◆ Twice a Month X 24 ◆ Monthly X 12
Directly Certified (DC) based on the State DC List as eligible for: ❑ SNAP ❑ TFA ❑ OT ❑ FM (Free Medicaid) ❑ RM (Reduced Medicaid). Date Certified on DC List: _________________
❑ SNAP/TFA Household providing proof (must be confirmed by DO) of a handwritten case number ❑ Foster Child ❑ Confirmed Head Start ❑ Confirmed Homeless or Runaway
❑ Income Household: Total household income: ______________ per _________________ Household Size: ____________________ ERROR PRONE? ❑ YES ❑ NO
Application approved for: ❑ Free Meals ❑ Reduced-price Meals ❑ Application Denied
Date Notice Sent: _____________________________________ Signature of DO: __________________________________________________ Date: ____________________________
Use of Information Statement ________________________________________________________________________________________________________________________________________________________________
The Richard B. Russell National School Lunch Act requires that we use information from The contact information below is solely to file a complaint of discrimination
this application to see who qualifies for free or reduced price meals. We can only approve
complete forms. We may share your eligibility information with education, health, and In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited
nutrition programs to help them deliver program benefits to your household. Inspectors from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or
and law enforcement may also use your information to make sure that program rules are retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require
met. alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the
Please be sure to provide the last four numbers of the Social Security number of the adult 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
household member who signs the application. If the adult does not have one, ‘Check if no Federal Relay Service at (800) 877-8339.
Social Security Number’. Applications for a foster child do not need to list a Social Security To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form
number. Applications for children in households receiving Supplemental Nutrition which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-
Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) or Food 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
Distribution Program on Indian Reservations (FDPIR) do not need to list a Social Security name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for
number. 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:
Some children qualify for free meals without an application. Please contact your school to
get free meals for a foster child, and children who are homeless, migrant, or runaway. * MAIL: U.S. Department of Agriculture FAX: (833) 256-1665 or (202) 690-7442; or * Do not mail applications to
Office of the Assistant Secretary for Civil Rights this address, only complaints
1400 Independence Avenue, SW EMAIL: Program.Intake@usda.gov of discrimination.
Return completed form to your child’s school. Washington, D.C. 20250-9410
This institution is an equal opportunity provider.
June 2023
Page 3 How to Apply for Free and Reduced-price School Meals
Please use these instructions to help you fill out the application for free or reduced-price school meals. You only need to submit one application per household, even if your children attend
more than one school in the Colchester School District. The application must be filled out completely to determine the eligibility of your children for free or reduced-price school meals.
Please follow these instructions in order! Each step of the instructions is the same as the steps o-n the application. If at any time you are not sure what to do next, please contact Leanne
Ranheim, JJIS, 215 Halls Hill Road, Colchester CT 06415, email at lranheim@colchesterct.org or call 860-537-9421 ext 6507.
PLEASE USE A PEN (NOT A PENCIL) WHEN FILLING OUT THE APPLICATION AND DO YOUR BEST TO PRINT CLEARLY.
Step 1: List ALL children, infants, and students up to and including grade 12
Tell us how many infants/toddlers, children not in school, and school students live in your household. They do NOT have to be related to you to be a part of your household.
Who should I list here? When filling out this section, please include ALL members in your household who are:
• Children age 18 or under AND are supported with the household’s income;
• In your care under a foster arrangement, through a court or state/local agency, or qualify as homeless or runaway youth;
• Students attending (regardless of age) Colchester Public Schools
A) List each child’s name. Print each child’s B) Is the child a student? List the name of C) Do you have any foster children? If any children listed are foster D) Are any children homeless, runaway or in
name. Use one line of the application for each the school (optional), the grade and mark “Yes” children, mark the “Foster Child” box next to the child’s name. If you a Head Start Program? If you believe any child
child. When printing names, please print or “No” under the column titled “Student” to tell are ONLY applying for foster children, after finishing STEP 1, go to listed in this section meets this description, mark
clearly. Stop if you run out of space. If there are us which children attend school in the district. If STEP 4. the “Head Start or Homeless/Runaway” box next
more children present than lines on the you marked “Yes,” write the grade level of the Foster children who live with you may count as members of your to the child’s name and complete all steps of the
application, attach a second piece of paper (or student in the “Grade” column. household and should be listed on your application. If you are applying application. Homeless, Runaway and Head Start
a second application if completing for both foster and non-foster children, go to step 3. Note: Adopted status must be confirmed with the appropriate
electronically) with all required information for children are not considered foster children. A foster child is a minor program staff. If the status cannot confirmed,
the additional children. This also applies to child who has been taken into state custody and placed with a state- then the school district will contact you to
adults in Step 3. “MI” is short for “middle initial”. licensed adult, who cares for the child in place of their parent or complete an income-based application. You may
Print the first letter of each child’s middle name guardian. choose to provide income information now in
in the “MI” section. order to prevent the school district from
potentially needing to contact you later.
Step 2: Do any household members currently participate in SNAP or TFA?
If anyone in your household (including you) currently participates in one or more of the assistance programs listed below, your children are eligible for free school meals:
• The Supplemental Nutrition Assistance Program (SNAP)
• Temporary Family Assistance (TFA)
A) If no one in your household B) If anyone in your household participates in SNAP or TFA:
participates in any of the above listed • Write a case number for SNAP or TFA. You only need to provide one case number. If you participate in one of these programs and do not know your
programs: case number, contact your DSS social worker.
• Leave STEP 2 blank and go to STEP Note: Do not use a HUSKY Medical Benefits number since this number is not a SNAP or TFA case number. It is also recommended (but not required) that
3. you submit proof of this SNAP or TFA case number when you submit the application for processing. Proof does NOT include a copy of the CONNECT card.
• -Go to STEP 4.
Step 3: Report income for all household members
How do I report my income?
• Use the charts titled “Sources of Income” and “Examples of Income for Children,” printed on the back side of the application form, to determine if your household has income to report.
• Report all amounts in GROSS INCOME ONLY. Report all income in whole dollars. Do not include cents.
o Gross income is the total income received before taxes.
o Many people think of income as the amount they “take home” and not the total “gross” amount. Make sure that the income you report on this application has NOT been reduced to
pay for taxes, insurance premiums, or any other amounts taken from your pay.
• Write a “0” in any fields where there is no income to report. Any income fields left empty or blank will also be counted as a zero. If you write ‘0’ or leave any fields blank, you are certifying
(promising) that there is no income to report. If local officials suspect that your household income was reported incorrectly, your application will be investigated.
• Mark how often each type of income is received using the check boxes to the right of each field.
June 2023
Page 4
How to Apply for Free and Reduced-price School Meals
3.A. Report income earned by children
A) Report all income earned or received by children. Report the combined gross income for ALL children listed in STEP 1 in your household in the box marked “Child Income.” Only count
foster children’s income if you are applying for them together with the rest of your household.
What is Child Income? Child income is money received from outside your household that is paid DIRECTLY to your children. Many households do not have any child income.
3.B. Report income earned by adults
Who should I list here?
• When filling out this section, please include ALL adult members in your household who are living with you and share income and expenses, even if they are not related and even if they do
not receive income of their own.
• Do NOT include:
o People who live with you but are not supported by your household’s income AND do not contribute income to your household.
o Infants, children and students already listed in STEP 1.
B) List adult household members’ names. Print C) Report earnings from work. Report all income from work in the “Earnings D) Report income from public assistance/child support/alimony.
the name of each household member in the from Work” field on the application. This is usually the money received from Report all income that applies in the “Public Assistance/Child
boxes marked “Names of Adult Household working at jobs. If you are a self-employed business or farm owner, you will Support/Alimony” field on the application. Do not report the cash
Members (First and Last).” Do not list any report your net income. Net income is your income after taxes and deductions value of any public assistance benefits NOT listed on the chart. If
household members you listed in STEP 1. If a have been subtracted. income is received from child support or alimony, only report
child listed in STEP 1 has income, follow the court-ordered payments. Informal but regular payments should
instructions in STEP 3, part A. • What if I have multiple jobs? List each job separately by entering your name be reported as “other” income in the next part.
and income from each job on a new line. Add an additional sheet of paper if
necessary.
• What if I am self-employed? List income from your business as a net amount.
This net amount is calculated by subtracting the total operating expenses of
your business from its gross receipts (revenue). Gross receipts or revenue are
all the income earned from the sale of any products or services offered.
E) Report income from pensions/retirement/all F) Report total household size. Enter the total number of household members G) Provide the last four digits of your Social Security Number. An
other income. Report all income that applies in in the field “Total Household Members (Children and Adults).” This number adult household member must enter the last four digits of their
the “Pensions/Retirement/All Other Income” MUST be equal to the number of household members listed in STEP 1 and STEP Social Security Number in the space provided. You are eligible to
field on the application. 3. If there are any members of your household that you have not listed on the apply for benefits even if you do not have a Social Security
• What if I receive income from multiple application, go back and add them. It is very important to list all household Number. If no adult household members have a Social Security
sources in this category? List each source members, as the size of your household affects your eligibility for free and Number, leave this space blank and mark the box to the right
separately by entering your name and income reduced-price meals. labeled “Check if no Social Security Number.”
from each source on a new line. Add an
additional sheet of paper if necessary.
Step 4: Contact information and adult signature
All applications must be signed by an adult member of the household. By signing the application, that household member is promising that all information has been truthfully and completely
reported. Before completing this section, please also make sure you have read the privacy and civil rights statements on the back of the application.
A) Provide your contact information. Write your B) Print and sign your name and write today’s date. Print the name of the adult C) Mail D) Share children’s racial and ethnic
current mailing address in the fields provided if signing the application and that person signs in the box “Signature of adult.” completed form identities (optional). On the back of the
this information is available. If you have no to Leanne application, we ask you to share information
permanent address, that is okay. Sharing a Please return the application directly to your child’s SCHOOL. Ranheim, JJIS, about your children’s race and ethnicity. This
phone number, email address, or both is DO NOT mail, fax, or email completed applications or questions about 215 Halls Hill Rd, field is optional and does not affect your
applications to the USDA Office of the Assistant Secretary for Civil Rights or
optional, but helps us reach you quickly if we Colchester CT children’s eligibility for free or reduced-price
your child’s eligibility for free or reduced-price meals will be delayed.
need to contact you. 06415 school meals.
Connecticut State Department of Education • Revised June 2023
https://portal.ct.gov/SDE/Nutrition/Eligibility-for-Free-and-Reduced-price-Meals-and-Milk-in-School-Nutrition-Programs/Documents