STEP 1: LIST ALL HOUSEHOLD MEMBERS WHO ARE INFANTS, CHILDREN, AND STUDENTS UP TO AND INCLUDING GRADE 12

Tell us how many infants, children, 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 grades 12  or under AND are supported with the household’s income; and
• In your care under a foster arrangement, or qualify as homeless, migrant, or runaway youth, or enrolled in a Head Start program.

A) List each child’s name. Print each child’s name. Use one line of the application for each child. When printing names, write one letter in each box. Stop if you run out of space. If there are more children in household than lines on the application, attach a second piece of paper with all required information for the additional children.

B) Enter the grade and the name of the school the child attends or mark n/a if not in school.

C) Do you have any foster children? If any children listed are foster children, mark the “Foster Child” box next to the children’s names. If you are ONLY applying for foster children, after finishing STEP 1, go to STEP 4. Foster children who live with you may count as members of your household and should be listed on your application. If you are applying for both foster and non-foster children, go to step 3. 

D) Are any children homeless, migrant, runaway or enrolled in a Head Start program? If you believe any child listed in this section meets this description, mark the “Homeless, Migrant, Runaway or Head Start” box next to the child’s name and complete all steps of the application.

STEP 2: DO ANY HOUSEHOLD MEMBERS CURRENTLY PARTICIPATE IN FoodShare, W-2 Cash Benefits OR FDPIR?

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) or FoodShare. 
• Temporary Assistance for Needy Families (TANF) or W-2 Cash Benefits.
• The Food Distribution Program on Indian Reservations (FDPIR).

A)  If no one in your household participates in any of the above listed programs:

• Leave STEP 2 blank or check “No” and go to STEP 3.

B)  If anyone in your household participates in any of the above assistance programs:

• Write a case number and name of the assistance program you or any member of the household participates for FoodShare, W-2 Cash Benefits, or FDPIR. You only need to provide one case number. If you participate in one of these programs and do not know your case number, contact your case worker. Medicaid and BadgerCare case numbers do NOT qualify for free or reduced price meals.
• 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 for Children” and “Sources of Income for Adults,” 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. Gross income is the total income received before taxes. Many people think of income as the amount they “take home” (listed as “net pay” on paycheck stub) 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 boxes to the right of each field.

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 personal 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

List adult household members’ names.

• Print the name of each household member in the boxes marked “Name of Adult Household Members (First and Last).” 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:
  
  • People who live with you but are not supported by your household’s income AND do not contribute income to your household.
  • Infants, children and students already listed in STEP 1.

C) Report earnings from work. Report all total gross income (before taxes) from work in the “Earnings from Work” field on the application. This is usually the money received from working at jobs. If you are a self-employed business or farm owner, you will report your net income.

What if I am self-employed? Report income from that work as a net amount. This is calculated by subtracting the total operating expenses of your business from its gross receipts or revenue.

 D) Report income from public assistance/child support/alimony/SSI/VA benefits. Report all income that applies in the “Public Assistance/Child Support/Alimony” field on the application. Do not report the cash value of any public assistance benefits NOT listed on the chart. If income is received from child support or alimony, only report court-ordered payments. Informal but regular payments should be reported as “other” income in the next part.

E) Report income from pensions/retirement/all other income. Report all income that applies in the “Pensions/Retirement/ Social Security/All Other Income” field on the application.

F) Fluctuating Income.  For seasonal workers and others whose income fluctuates and usually earn more money in some months than others.  In these situations, project the annual rate of income and report that.  This includes workers with annual employment contracts but may choose to have salaries paid over a shorter period of time; for example, school employees. 

G) Report total household size. Enter the total number of household members in the field “Total Household Members (Children and Adults).” This number MUST be equal to the number of household members listed in STEP 1 and STEP 3. If there are any members of your household that you have not listed on the application, go back and add them. It is very important to list all household members, as the size of your household affects your eligibility for free and reduced price meals.

H) Provide the last four digits of your Social Security Number (SSN). An adult household member must enter the last four digits of their SSN in the space provided. You are eligible to apply for benefits even if you do not have a SSN. If no adult household members have a SSN, leave this space blank and mark the box to the right labeled “Check box if no SSN.”

STEP 4: CONTACT INFORMATION AND ADULT SIGNATURE

An adult member of the household must sign the application. 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 current address in the fields provided if this information is available. If you have no permanent address, this does not make your children ineligible for free or reduced price school meals. Sharing a phone number, email address, or both is optional, but helps us reach you quickly if we need to contact you.

B) Print or sign your name.  The adult filling out the application must print or sign their name in the signature box.

C) Return completed form to: Dina Lane,

School District of Hartford Joint #1,

402 W. Sumner Street

Hartford, WI  53027

D) Share children’s racial and ethnic identities (optional). On the back of the application, we ask you to share information about your children’s race and ethnicity. This field is optional and does not affect your children’s eligibility for free or reduced price school meals.