Machine-extracted text of a publicly
posted document, provided for reference and search. The original document at
the link above is authoritative.
June 2021 2021-22 Application for Free and Reduced-price School Meals or Free Milk
Page 1 Complete one application per household. Please use a pen (not a pencil). Application No: ______________
List ALL Household Members who are infants, children and students up to and including grade 12. (If more spaces are required for additional names, attach another
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 and
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:
complete STEP 3.) To quicken the approval process, it is strongly recommended that you submit proof of SNAP or TFA eligibility with
Write only one case number in this space.
this application. See instructions.
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 income earned by all Child Household
here? Members listed in STEP 1 here. $
Flip the page and B. All Adult Household Members (including yourself)
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)
“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? How often? How often? Pensions/Retirement/ How often?
Name of Adult Household Members Public Assistance/
The “Sources of All Other Income Weekly Bi-Weekly 2x Month Monthly Annual
(First & Last Name) Earnings from Work 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.
$ $ $ $
Total Household Members
Last Four Digits of Social Security Number (SSN) of
(Children and Adults –
Primary Wage Earner or Other Adult Household Member
X X X X X Check if no SSN ☐
Step 1 & Step 3)
STEP 4 Contact
Contact Information
informationand
andAdult
adultSignature.
signature Mail completed form to: JJIS ATTN: Leanne Ranheim 215 Halls Hill Rd, Colchester CT 06415
“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.”
Street Address (if available) Apt # City State Zip Daytime Phone and Email (optional)
Printed name of adult signing the form Signature of adult Today’s date
June 2021 2021-22 Application for Free and Reduced-price School Meals or Free Milk
Page 2
Sources of Income for Children Sources of Income for Adults
Sources of Child Public Assistance/Alimony/ Pensions/Retirement/
Examples Earnings from Work
Income Child Support All Other Income
Earnings from work A child has a regular or part-time job where they earn a
salary or wages Gross income for salary, wages, cash Unemployment benefits Social Security (including railroad
-- bonuses Worker’s compensation retirement and black lung benefits)
Social Security A child is blind or disabled and receives Social Security Net income from self-employment Supplemental Security Income Private pensions or disability
Disability benefits (farm or business) (SSI) Regular Income from trusts or
Payments Cash assistance from state or estates
A parent is disabled, retired, or deceased, and their child If you are in the U.S. Military: local government Annuities
Survivor’s
receives social security benefits
Benefits Alimony payments Investment income
Income from A friend or extended family member regularly gives a child Basic pay and cash bonuses (do NOT Child support payments Earned Interest
persons outside the spending money include combat pay, FSSA or Veteran’s benefits Rental income
household privatized housing allowances) Strike benefits Regular cash payments from
Income from any A child receives income from a private pension fund, annuity, outside household
other source or trust Allowances for off-base housing, food
and clothing
OPTIONAL Children’s Racial and Ethnic Identities
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 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
Persons with disabilities who require alternative means of communication for program information (e.g. Braille,
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. large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they
You must include the last four digits of the social security number of the adult household member who signs the applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA
application. The last four digits of the social security number is not required when you apply on behalf of a through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made
foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy available in languages other than English.
Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form,
FDPIR identifier for your child or when you indicate that the adult household member signing the application (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a
does not have a social security number. We will use your information to determine if your child is eligible for letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy
free or reduced-price meals, and for administration and enforcement of the lunch and breakfast programs. We
of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
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 mail: U.S. Department of Agriculture
help them look into violations of program rules. Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations Washington, D.C. 20250-9410
and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering fax: (202) 690-7442; or
USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or
email: program.intake@usda.gov.
reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
This institution is an equal opportunity provider.
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 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: ____________________________
June 2021
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 Public Schools. The application must be filled out completely to certify 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 on the application. If at any time you are not sure what to do
next, please contact Leanne Ranheim at 860-537-9421 ext 381 or email at lranheim@colchesterct.org.
PLEASE USE A PEN (NOT A PENCIL) WHEN FILLING OUT THE APPLICATION AND DO YOUR BEST TO PRINT CLEARLY.
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 age 18 or under AND are supported with the household’s income;
In your care under a foster arrangement, or qualify as homeless or runaway youth;
Students attending Colchester Public Schools, regardless of age.
A) List each child’s name. Print each B) Is the child a student in the C) Do you have any foster children? If any children listed D) Are any children homeless,
child’s name. Use one line of the district? List the name of the school, are foster children, mark the “Foster Child” box next to runaway or in a Head Start Program?
application for each child. When the grade and mark “Yes” or “No” the child’s name. If you are ONLY applying for foster If you believe any child listed in this
printing names, please print clearly. If under the column titled “Student” to children, after finishing STEP 1, go to STEP 4. section meets this description, mark
there are more children present than tell us which children attend school in Foster children who live with you may count as members the “Head Start or
lines on the application, attach a the district. If you marked “Yes,” of your household and should be listed on your Homeless/Runaway” box next to the
second piece of paper with all write the grade level of the student in application. If you are applying for both foster and non- child’s name and complete all steps of
required information for the the “Grade” column. foster children, go to step 3. the application.
additional children.
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 any of the above listed programs:
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
programs: not know your case number, contact your DSS social worker.
Leave STEP 2 blank and go to 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
STEP 3. required) that 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 for Children” and “Sources of Income for Adult,” 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 2021
Page 4
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. C) Report earnings from work. Report all income from work in the D) Report income from public assistance/child
Print the name of each household “Earnings from Work” field on the application. This is usually the money support/alimony. Report all income that applies in the
member in the boxes marked “Names of received from working at jobs. If you are a self-employed business or farm “Public Assistance/Child Support/Alimony” field on the
Adult Household Members (First and owner, you will report your net income. application. Do not report the cash value of any public
Last).” Do not list any household members assistance benefits NOT listed on the chart. If income is
What if I am self-employed? Report income from that work as a net
you listed in STEP 1. If a child listed in received from child support or alimony, only report court-
amount. This is calculated by subtracting the total operating expenses of
STEP 1 has income, follow the ordered payments. Informal but regular payments should
your business from its gross receipts or revenue.
instructions in STEP 3, part A. be reported as “other” income in the next part.
E) Report income from F) Report total household size. Enter the total number of household G) Provide the last four digits of your Social Security
pensions/retirement/all other income. members in the field “Total Household Members (Children and Adults).” Number. An adult household member must enter the last
Report all income that applies in the This number MUST be equal to the number of household members listed four digits of their Social Security Number in the space
“Pensions/Retirement/All Other Income” in STEP 1 and STEP 3. If there are any members of your household that you provided. You are eligible to apply for benefits even if you
field on the application. have not listed on the application, go back and add them. It is very do not have a Social Security Number. If no adult
important to list all household members, as the size of your household household members have a Social Security Number, leave
affects your eligibility for free and reduced-price meals. this space blank and mark the box to the right labeled
“Check if no SSN.”
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. B) Print and sign your name and write today’s date. Print the name of the C) Mail D) Share children’s racial and ethnic
Write your current address in the fields adult signing the application and that person signs in the box “Signature of completed identities (optional). On the back of the
provided if this information is available. If adult.” form to JJIS, application, we ask you to share
you have no permanent address, this ATTN: Leanne information about your children’s race
does not make your children ineligible for Ranheim 215 and ethnicity. This field is optional and
free or reduced-price school meals. Halls Hill Rd, does not affect your children’s eligibility
Sharing a phone number, email address, Colchester Ct for free or reduced-price school meals.
or both is optional, but helps us reach you 06415.
quickly if we need to contact you.
Connecticut State Department of Education Revised June 2021
https://portal.ct.gov/SDE/Nutrition/Eligibility-for-Free-and-Reduced-price-Meals-and-Milk-in-School-Nutrition-Programs/Documents