LAWRENCE COUNTY SCHOOLS

Dear Parent/Guardian:

Children need healthy meals to learn. Lawrence County Schools offers healthy meals every school day. Breakfast costs $1.00 at all schools; lunch costs $1.50 ($1.75 at LCHS). Your children may qualify for free meals or for reduced price meals. Reduced price is $0.30 for breakfast and $0.40 for lunch.

Do I need to fill out an application for each child? No. Complete the application to apply for free or reduced price meals. Use one Free and Reduced Price School Meals 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: Karen Ferrell, Lawrence County Board of Education, 50 Bulldog Lane, Louisa, KY 41230 or call 606-638-9671 ext 26 if you need assistance.
Who can get free meals? All children in households receiving benefits from SNAP or KTAP, can get free meals regardless of your income. Also, your children can get free meals if your household’s gross income is within the free limits on the Federal Income Eligibility Guidelines.
CAN FOSTER CHILDREN GET FREE MEALS? Yes, foster children that are under the legal responsibility of a foster care agency or court, are eligible for free meals. Any foster child in the household is eligible for free meals regardless of income.

Can homeless, runaway, and migrant children get free meals? Yes, children who meet the definition of homeless, runaway, or migrant qualify for free meals. If you haven’t been told your children will get free meals, please call or e-mail Thomas Gibson, Lawrence County Board of Education, at 606-638-9671 ext 17 or Thomas.gibson@lawrence.kyschools.us to see if they qualify.
WHO CAN GET REDUCED PRICE MEALS? Your children can get low cost meals if your household income is within the reduced price limits on the Federal Eligibility Income Chart, shown on this application.
SHOULD I FILL OUT AN APPLICATION IF I RECEIVED A LETTER THIS SCHOOL YEAR SAYING MY CHILDREN ARE APPROVED FOR FREE MEALS? Please read the letter you got carefully and follow the instructions. Call the LCBOE at 606-638-9671 ext 26 if you have questions.
MY CHILD’S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT ANOTHER ONE? Yes. Your child’s application is only good for that school year and for the first few days of this school year. You must send in a new application unless the school told you that your child is eligible for the new school year.
I GET WIC. CAN MY CHILD(REN) GET FREE MEALS? Children in households participating in WIC may be eligible for free or reduced price meals. Please fill out an application.
Will the information I give be checked? Yes and we may also ask you to send written proof.
If I don’t qualify now, may I apply later? Yes, you may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free and reduced price meals if the household income drops below the income limit.
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 to:
Mike Armstrong, Superintendent Phone: 606-638-9671 Address: Lawrence County Board of Education, 50 Bulldog Lane, Louisa, KY 41230
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 U.S. citizens to qualify for free or reduced price meals.
Who should I include as members of my household? You must include all people living in your household, related or not (such as grandparents, other relatives, or friends) who share income and expenses. You must include yourself and all children living with you. If you live with other people who are economically independent (for example, people who you do not support, who do not share income with you or your children, and who pay a pro-rated share of expenses), do not include them.
What if my income is not always the same? List the amount that you normally receive. For example, if you normally make $1000 each month, but you missed some work last month and only made $900, put down that you made $1000 per month. If you normally get overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income.
We are in the military. do we include our housing allowance as income? If you get an off-base housing allowance, it must be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income.
My spouse is deployed to a combat zone. is her combat pay counted as income? No, if the combat pay is received in addition to her basic pay because of her deployment and it wasn’t received before she was deployed, combat pay is not counted as income. Contact your school for more information.
My family needs more help. Are there other programs we might apply for? To find out how to apply for SNAP, KTAP or other assistance benefits, contact your local assistance office.

If you have other questions or need help, call 606-638-9671

Si necesita ayuda, por favor llame al teléfono: 606-638-9671

Si vous voudriez d’aide, contactez nous au numero 606-638-9671

Sincerely,

Lawrence County Schools Food Service

INSTRUCTIONS FOR APPLYING

A household member is any child or adult living with you.

If your household receives benefits from SNAP OR KTAP, follow these instructions:

Part 1: List all household members and the name of school for each child.

Part 2: List the case number for any household member (including adults) receiving SNAP or KTAP benefits.

Part 3: Skip this part.

Part 4: Skip this part.

Part 5: Sign the form. The last four digits of a Social Security Number are not necessary.

Part 6: Answer this question if you choose to.

if no one in your household gets SNAP or KTAP benefits and if any child in your household is homeless, a migrant or runaway, follow these instructions:

Part 1: List all household members and the name of school for each child.

Part 2: Skip this part.

Part 3: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call LCBOE, Thomas Gibson @606-638-9671

Part 4: Complete only if a child in your household isn’t eligible under Part 3. See instructions for All Other Households.

Part 5: Sign the form. The last four digits of a Social Security Number are not necessary if you didn’t need to fill in Part 4.

Part 6: Answer this question if you choose to.

If you are applying for a FOSTER CHILD, follow these instructions:

If all children in the household are foster children:

Part 1: List all foster children and the school name for each child. Check the box indicating the child is a foster child.

Part 2: Skip this part.

Part 3: Skip this part.

Part 4: Skip this part.

Part 5: Sign the form. The last four digits of a Social Security Number are not necessary.

Part 6: Answer this question if you choose to.

If some of the children in the household are foster children:

Part 1: List all household members and the name of school for each child. For any person, including children, with no income, you must check the “No Income” box. Check the box if the child is a foster child.

Part 2: If the household does not have a case number, skip this part.

Part 3: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call LCBOE, Thomas Gibson @606-638-9671 . If not, skip this part.

Part 4: Follow these instructions to report total household income from this month or last month.

· Box 1–Name: List all household members with income.

· Box 2 –Gross Income and How Often It Was Received: For each household member, list each type of income received for the month. You must tell us how often the money is received—weekly, every other week, twice a month or monthly. For earnings, be sure to list the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. For other income, list the amount each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), and disability benefits. Under All Other Income, list Worker’s Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income. Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster payments received by the family from the placing agency. For ONLY the self-employed, under Earnings from Work, report income after expenses. This is for your business, farm, or rental property. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income.

Part 5: Adult household member must sign the form and list the last four digits of their Social Security Number (or mark the box if s/he doesn’t have one).

Part 6: Answer this question, if you choose.

ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:

Part 1: List all household members and the name of school for each child. For any person, including children, with no income, you must check the “No Income” box.

Part 2: If the household does not have a case number, skip this part.

Part 3: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call LCBOE, Thomas Gibson @606-638-9671 . If not, skip this part.

Part 4: Follow these instructions to report total household income from this month or last month.

· Box 1–Name: List all household members with income.

· Box 2 –Gross Income and How Often It Was Received: For each household member, list each type of income received for the month. You must tell us how often the money is received—weekly, every other week, twice a month or monthly. For earnings, be sure to list the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. For other income, list the amount each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), and disability benefits. Under All Other Income, list Worker’s Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income. Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster payments received by the family from the placing agency. For ONLY the self-employed, under Earnings from Work, report income after expenses. This is for your business, farm, or rental property. Do not include income from SNAP, FDPIR, WIC or Federal education benefits. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income.

Part 5: Adult household member must sign the form and list the last four digits of their Social Security Number (or mark the box if s/he doesn’t have one).

Part 6: Answer, this question if you choose.

FREE AND REDUCED PRICE SCHOOL MEALS FAMILY APPLICATION

Part 1. all household members
Names of all household members (First, Middle Initial, Last)		Name of school for each child/or indicate “NA” if child is not in school		Check if a foster child (legal responsibility of welfare agency or court) * If all children listed below are foster children, skip to Part 5 to sign this form.			Check if NO income
				q			q
				q			q
				q			q
				q			q
				q			q
				q			q
Part 2. BENEFITS If any member of your household receives SNAP, or KTAP , provide the name and case number for the person who receives benefits and skip to part 5. if no one receives these benefits, skip to part 3. name:____________________________________________________________________ Case number: __________________________________________________________
Part 3. If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call LCBOE, Thomas Gibson @606-638-9671 Homeless q Migrant q Runaway q
Part 4. Total Household Gross Income. You must tell us how much and how often.
1. Name (List only household members with income)	2. Gross income and how often it was received fOR EXAMPLE: WEEKLY, EVERY OTHER WEEK, TWICE MONTHLY, MONTHLY
	Earnings From Work before deductions		Welfare, child support, alimony		Pensions, retirement, Social Security, SSI, VA benefits	All Other Income
(Example) Jane Smith
	$______/________		$______/________		$______/________	$______/_______
	$______/________		$______/________		$______/________	$______/_______
	$______/________		$______/________		$______/________	$______/_______
	$______/________		$______/________		$______/________	$______/_______
	$______/________		$______/________		$______/________	$______/_______
	$______/________		$______/________		$______/________	$______/_______

Part 5. Signature and last four digits of Social Security Number (Adult must sign)
An adult household member must sign the application. If Part 4 is completed, the adult signing the form also must list the last four digits of his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on the back of this page.) I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted. Sign here: ______________________________________________________________________Print name:_____________________________ Date: ____________________________ Address:_____________________________________________________________________________________Phone Number:______________ City:___________________________________________________________________________State:__________________Zip Code:___________ Last four digits of Social Security Number: * * * - * * - __ __ __ __ q I do not have a Social Security Number
Part 6. Children’s ethnic and racial identities (optional)
Choose one ethnicity:	Choose one or more (regardless of ethnicity):
q Hispanic/Latino q Not Hispanic/Latino	q Asian q American Indian or Alaska Native q Black or African American q White q Native Hawaiian or other Pacific Islander
Do NOt fill out this part. This is for school use only.
Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24 Monthly x 12 Total Income: ____________ Per: q Week, q Every 2 Weeks, q Twice A Month, q Month, q Year Household size: ________ Categorical Eligibility: ___ Date Withdrawn: ________Eligibility: Free___ Reduced___ Denied___ Reason: ________________________________________________________________________________ Temporary: Free_____ Reduced_____ Time Period: ___________ (expires after _____ days) Determining Official’s Signature: ________________________________________________ Date: ______________ Confirming Official’s Signature: _____________________________ Date: ___________ Verifying Official’s Signature: _______________________________Date: ________

FEDERAL ELIGIBILITY INCOME CHART For School Year 2011-12________
Household size	Yearly	Monthly	Weekly
1	20,147	1,679	388
2	27,214	2,268	524
3	34,281	2,857	660
4	41,348	3,446	796
5	48,415	4,035	932
6	55,482	4,624	1,067
7	62,549	5,213	1,203
8	69,616	5,802	1,339
Each additional person:	7,067	589	136

Your children may qualify for free or reduced price meals if your household income falls at or below the limits on this chart.

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 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.

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 USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.”

SHARING INFORMATION WITH MEDICAID/KCHIP

Dear Parent/Guardian:

If your children get free or reduced price school meals, they may also be able to get free or low-cost health insurance through Medicaid or the State Children's Health Insurance Program (KCHIP). Children with health insurance are more likely to get regular health care and are less likely to miss school because of sickness.

Because health insurance is so important to children’s well-being, the law allows us to tell Medicaid and KCHIP that your children are eligible for free or reduced price meals, unless you tell us not to. Medicaid and KCHIP only use the information to identify children who may be eligible for their programs. Program officials may contact you to offer to enroll your children. Filling out the Free and Reduced Price School Meals Application does not automatically enroll your children in health insurance.

If you do not want us to share your information with Medicaid or KCHIP, fill out the form below and send in (Sending in this form will not change whether your children get free or reduced price meals).

q No! I DO NOT want information from my Free and Reduced Price School Meals Application shared with Medicaid or the Kentucky Children's Health Insurance Program.

If you checked no, fill out the form below to ensure that your information is NOT shared for the child(ren) listed below:

Child's Name: ___________________________________________School:___________________________________________

Signature of Parent/Guardian: ______________________________________________Date: ______________

Printed Name:________________________________________________________________________________

Address:_____________________________________________________________________________________

For more information, you may call [name] at [phone] or e-mail at [e-mail address].

Return this form to: [address] by [date].

SHARING INFORMATION WITH OTHER PROGRAMS

Dear Parent/Guardian:

To save you time and effort, the information you gave on your Free and Reduced Price School Meals Application may be shared with other programs for which your children may qualify. For the following programs, we must have your permission to share your information. Sending in this form will not change whether your children get free or reduced price meals.

q Yes! I DO want school officials to share information from my Free and Reduced Price School Meals Application with [name of program specific to your school].

If you checked yes to any or all of the boxes above, fill out the form below to ensure that your information is shared for the child(ren) listed below. Your information will be shared only with the programs you checked.

Child's Name: ___________________________________________School:___________________________________________

Signature of Parent/Guardian: ______________________________________________Date: ______________

Printed Name:________________________________________________________________________________

Address:_____________________________________________________________________________________

_____________________________________________________________________________________________

For more information, you may call [name] at [phone] or e-mail at [e-mail address].

Return this form to: [address] by [date].

WE MUST CHECK YOUR APPLICATION

You must send the information we need, or contact [name] by [date], or your child(ren) will stop getting free or reduced price meals.

School: _______________________________________________________________ Date: __________________

Dear ___________________________________________________:

We are checking your Free and Reduced Price School Meals Application. Federal rules require that we do this to make sure only eligible children get free or reduced price meals. You must send us information to prove that [name(s) of child(ren)][is/are] eligible.

If possible, send copies, not original papers. If you do send originals, they will be sent back to you only if you ask.

1. If you were receiving benefits from [State SNAP], [State KTAP] or [FDPIR]when you applied for free or reduced price meals, or at any time since then, send us a copy of one of these:

· [State SNAP] or [State KTAP] or [FDPIR] Certification Notice that shows dates of certification.

· Letter from [State SNAP] or [State KTAP] or [FDPIR] office that shows dates of certification.

· Do not send your EBT card.

2. If you get this letter for a homeless, migrant, or runaway child, please contact [school, homeless liaison, or migrant coordinator] for help.

3. If the child is a Foster Child:

Provide written documentation that verifies the child is the legal responsibility of the agency or court or provide the name and contact information for a person at the agency or court who can verify that the child is a foster child.

4. If no one in your household receives [State SNAP] or [State KTAP] or [FDPIR] benefits:

Send this page along with papers that show the amount of money your household gets from each source of income. The papers you send must show the name of the person who received the income, the date it was received, how much was received, and how often it was received. Send information to: [address]

Acceptable papers include:

Jobs: Paycheck stub or pay envelope that shows the amount and how often pay is received; letter from employer stating gross wages and how often you are paid; or, if you work for yourself, business or farming papers, such as ledger or tax books.

Social Security, Pensions, or Retirement: Social Security retirement benefit letter, statement of benefits received, or pension award notice.

Unemployment, Disability, or Worker’s Comp: Notice of eligibility from State employment security office, check stub, or letter from the Worker’s Compensation’s office.

Welfare Payments: Benefit letter from the [State KTAP] office.

Child Support or Alimony: Court decree, agreement, or copies of checks received.

Other income (such as rental income): Information that shows the amount of income received, how often it is received, and the date received.

No income: A brief note explaining how you provide food, clothing , and housing for your household, and when you expect an income.

Military Housing Privatization Initiative: Letter or rental contract showing that your housing is part of the Military Privatized Housing Initiative.

Timeframe of Acceptable Income Documentation: Please submit proof of one month’s income; you could use the month prior to application, the month you applied, or any month after that.

If you have questions or need help, please call [name] at [phone number]. The call is free. [Toll free or reverse charge explanation]. You may also e-mail us at [e-mail address].

Sincerely,

[signature]

Privacy Act Statement: 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. 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.

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 USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.”

School: __________________________________________________________________ Date: ____________

We checked the information you sent us to prove that [name(s) of child(ren)] are eligible for free or reduced price meals and have decided that:

q Starting [date], your child(ren)’s eligibility for meals will be changed from reduced price to free because your income is within the free meal eligibility limits. Your child(ren) will receive meals at no cost.

q Starting [date], your child(ren)’s eligibility for meals will be changed from free to reduced price because your income is over the limit. Reduced price meals cost [$] for lunch and [$] for breakfast.

q Starting [date], your child(ren) is/are no longer eligible for free or reduced price meals for the following reason(s):

___ Records show that no one in your household received [State SNAP] or [State TANF] benefits.

___ You did not provide: ______________________________________________________________________________________

Meals cost [$] for lunch and [$] for breakfast. If your household income goes down or your household size goes up, you may apply again. If you were previously denied benefits because no one in the household received [State SNAP], [State TANF] or [FDPIR] benefits, you may reapply based on income eligibility. If you did not provide proof of current eligibility, you will be asked to do so if you reapply.

If you disagree with this decision, you may discuss it with [name] at [phone]. You also have the right to a fair hearing. If you request a hearing by [date], your child(ren) will continue to receive free or reduced price meals until the decision of the hearing official is made. You may request a hearing by calling or writing to: [name], [address], [phone number], or [e-mail].

q Approved for reduced price meals at $ __________ for lunch, $ ____________ for breakfast, and $ ____________ for snacks

q Incomplete application because _____________________________________________________________________

If you do not agree with the decision, you may discuss it with [school official’s name] at [phone number] or at [e-mail address]. If you wish to review the decision further, you have a right to a fair hearing. This can be done by calling or writing the following official:

NAME: _____________________________________________________________________________________________

ADDRESS: _____________________________________________________________________________________________

PHONE NUMBER: ____________________________________ E-MAIL _______________________________

____________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

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 USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.”

We want to let you know that the child(ren) listed below will receive free lunches, breakfasts, and snacks at school because they receive [State SNAP] or [StateKTAP].

If there are other children in your household who aren’t listed above, they also qualify for free meals.

Please contact the school your child/children attend in the following situations:

· If there are other children in your household who are not listed above and you would like them to receive free meals at school

School Year 2011-2012____

Instructions For School Districts

A household member is any child or adult living with you.

If your household receives benefits from SNAP OR KTAP, follow these instructions:

FREE AND REDUCED PRICE SCHOOL MEALS FAMILY APPLICATION

SHARING INFORMATION WITH MEDICAID/KCHIP

SHARING INFORMATION WITH OTHER PROGRAMS

WE MUST CHECK YOUR APPLICATION

WE HAVE CHECKED YOUR APPLICATION

notice to households of approval/denial of benefits

Notice of Direct Certification