Form 3C Applications
Page 1, 2 and 4
June 01, 2008
Dear Parent/Guardian:
Your child may be eligible to receive healthy school meals at a
reduced price or free. Following are questions and answers about
who is eligible and how to apply.
| Elementary | Middle School | High School | ||||
| Full Price | Reduced Price | Full Price | Reduced Price | Full Price | Reduced Price | |
| National School Lunch Program | ||||||
| School Breakfast Program | ||||||
| After School Care Snack Program | No Chg | No Chg | N/A | N/A | N/A | N/A |
1. Do I need to fill out an application for each
child? No. Complete one application for all students in your
household. We cannot approve an application that is not complete,
so be sure to fill out all required information. Return the
completed application to: Carol McKenna Address: 401 N.Ninnescah,
Pratt, KS 67124 Phone: 620-672-4500.
2. Who can get free meals? Students in households getting Food
Stamps, TAF or FDPIR and most foster children can get free meals
regardless of your income. Also, students in your household can get
free meals if your household income is within the free limits on
the Federal Income Guidelines.
3. Can a homeless, runaway or migrant student get free meals? If you have not already been informed that the student will get free meals, to see if he or she qualifies, please call Carol McKenna Phone: 620-672-4500 .
4. Who can get reduced price meals? Students in your household can get reduced price meals if your household income is within the reduced price limits on the Federal Income Chart (see the back of the application form).
5. If I already received a letter from the school or Kansas State Department of Education that says my child(ren) will receive free meals, do I need to complete an application? No, you do not need to complete an application. If you did not receive a letter from the school notifying you that your child(ren) will get free meals, bring the Kansas State Department of Education letter to the school.
6. I get WIC. Can my child(ren) get free meals? Students in households participating in WIC may be eligible for reduced price or free meals. Please fill out an application.
7. Will the information I give be checked? Yes, we may ask you to send written proof.
8. If I don’t qualify now, may I apply later? Yes. You may apply at any time during the school year if your household size goes up, income goes down, or if you start getting Food Stamps, TAF, FDPIR or other benefits. If you lose your job, your children may be able to get reduced price or free meals during the unemployment period.
9. What if I disagree with the school’s decision about my application? You should talk to school officials. You also may ask for a hearing by calling or writing: Glen Davis Address: 401 N. Ninnescah, Pratt, KS 67124 Phone: 620-672-4500.
10. May I apply if someone in my household is not a U.S. citizen? Yes. You or your child(ren) do not have to be a U.S. citizen to qualify for reduced price or free meals.
11. Who should I include as members of my household? Include all people living in your household, related or not (such as grandparents, other relatives, or friends). Include yourself and all children who live with you.
12. What if my gross income is not always the same? List the amount that you normally get. For example, if your normal gross income is $1,000 each month, but you missed some work last month and only got $900, put down that you get $1,000 per month. If you normally get overtime, include it, but not if you get it only sometimes.
13. We are in the military, do we include our housing allowance as income? If your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income.
All other allowances must be included in your gross income.
If you have other questions or need help, call
620-672-4500.
Si necesita ayuda, por favor llame al teléfono 620-672-4500.
Si vous voudriez d’aide, contactez nous au numero 620-672-4500.
Form 3-C 5 /2008 – Page 1
How to Apply for Reduced Price or Free School Meals
If your household gets FOOD STAMPS, TAF or
FDPIR, follow these instructions:
Part 1:
- Enter each student’s first and last name.
- Enter each student’s school and grade.
- Enter a Food Stamp, TAF or FDPIR case number for each student.
Part 2: Sign and date the form. A Social
Security number is not necessary.
Part 3: Complete this part if you choose to.
If you are applying for a FOSTER CHILD,
follow these instructions:
Part 1: Use a separate application for each foster
child.
- Check the box on line 1.
- Enter the student’s first and last name.
- Enter the student’s school and grade.
- Check the box if the student has zero personal use income.
- If the student has personal use income, enter the amount and circle the Frequency code that shows how often the income is received.
Part 2: Sign and date the form. A Social
Security number is not necessary.
Part 3: Complete this part if you choose to.
ALL OTHER HOUSEHOLDS, including WIC
households, follow these instructions:
Part 1: Report the names and GROSS income for all
household members from last month. Gross income is the amount
earned BEFORE taxes and any other deductions. This is NOT the same
as take-home pay. The gross amount should be listed on the pay
stub.
- Students:
• Enter the student’s first and last name
• Enter the student’s school and grade.
• Check the box if the student has zero income.
• If the student has income, record the amount in the column that best describes the source
of the income (i.e. Earnings from Work or Other Regular Income) and circle the Frequency code that shows how often the income is received. - All Other
Household Members:
• List the first and last name of each person living in your household, related or not (such as grandparents, other relatives, or friends). Include yourself and all children living with you who are not already listed as students. Attach another sheet of paper if more space is
needed.
• Check the box if the person has zero income.
• List the gross income the person earned from work and circle the Frequency code that
shows how often the income is received.
• List the amount the person got last month from other income including welfare, child
support, alimony, retirement pensions, Social Security, Worker’s Compensation,
unemployment, strike benefits, Supplemental Security Income (SSI), veteran’s benefits (VA benefits), disability benefits, regular contributions from people who do not live in your household, and ANY OTHER INCOME. Circle the Frequency code that shows how often the income is received.
• If the household has income from self-employment (such as from a self-owned business,farm or rental income), report net income in the Earnings from Work columns. See the
back side of the application form for instructions on reporting self-employment income.
• If the household is in the Military Housing Privatization Initiative do NOT include this housing allowance.
• Check the box if this person is not working due to strike, lay-off, injury or short-term
disability.
Part 2: An adult household member must sign
the form and list his or her Social Security number or write “NONE”
if he or she does not have one.
Part 3: Complete this part if you choose to.
Form 3-C 5 /2008 – Page 2
2008-2009 Application for Child Nutrition Program Benefits
(This form can be found in the PDF Version of Online Enrollment Forms PLEASE PRINT and COMPLETE)
(Important! Carefully follow instructions. An incomplete application cannot be approved. Complete one application per foster child OR household. Return completed application to school)
Form 3-C 5 /2008 – Page 3
Your children may qualify for reduced price or free meals if your household income falls within the limits on this chart.
| 2008-2009 Federal Income Eligibility Guidelines | |||||
| Household Size | Yearly | Monthly | Twice a Month | Every 2 Weeks | Weekly |
| 1 | 19,200 | 1,604 | 802 | 740 | 370 |
| 2 | 25,900 | 2,159 | 1,080 | 997 | 499 |
| 3 | 32,560 | 2,714 | 1,357 | 1,253 | 627 |
| 4 | 39,220 | 3,269 | 1,635 | 1,509 | 755 |
| 5 | 45,880 | 3,824 | 1,912 | 1,765 | 883 |
| 6 | 52,540 | 4,379 | 2,190 | 2,021 | 1,011 |
| 7 | 59,200 | 4,934 | 2,467 | 2,277 | 1,139 |
| 8 | 65,860 | 5,489 | 2,745 | 2,534 | 1,267 |
| Each Additional Person | 6,660 | 555 | 278 | 257 | 129 |
Income from Self Employment: Self-employed persons may use
income tax records for the preceding calendar year as a base to
project the current year’s net income, unless the current monthly
income provides a more accurate measure. Report income derived from
the business venture less operating costs incurred in the
generation of that income. Deductions for personal expenses such as
interest on home payments, medical expenses, and other similar
non-business deductions are not allowed in reducing gross business
income. Additional income from other kinds of employment must be
treated as separate and apart from the income generated or lost
from your business venture. For example, if you operated a business
at a net loss, but held additional employment for which a salary
was received, the income for purposes of applying for reduced price
or free meals would be the income from the salary only. The loss
from the business cannot be deducted from a positive income earned
in other employment. For purposes of this application, it is not
possible to report a negative income from any business venture. The
least income possible is zero (no income). The necessary
information for arriving at allowable income from private business
operation may be taken from your most recent U.S. Individual Income
Tax Return - Form 1040. Add together the amounts reported on the
following lines:
LINE 12 $Business Income or (Loss)
LINE 13 $Capital Gain
or (Loss)
LINE 14 $Other Gains
or (Losses)
LINE 17 $Rental real
estate, royalties, partnerships, S corporations, trusts, etc.
LINE 18 $Farm Income
or (Loss)
TOTAL $Report yearly income in Part 1, Gross Income Before Any
Deductions
Privacy Act Statement: This explains how we will use the information you give us. 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 reduced price or free meals. You must include the Social Security number of the adult household member who signs the application. The Social Security number is not required when you apply on behalf of a foster child or you list a Food Stamp Program, Temporary Assistance for Families (TAF) 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 reduced price or free 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.
Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington DC 20250-9410 or call (800) 795-3272 or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.
Form 3-C 5 /2008 – Page 4
