Application for Free and Reduced Price School Meals

Welcome to the free and reduced price school meals application for Springfield Academy.

This application has 4 sections to fill out, but the system may automatically skip sections based on the answers you give. It takes approximately 10 minutes to complete and you will have the chance to review before submitting. Submitting this application carries no risk to you, regardless of the final outcome.

If you have questions, please contact John Doe at 123-456-7890 or john.doe@springfield.edu.

To get started, please sign your first & last name below.

This field is required

The person signing is furnishing true information and to advise that person that the application is being made in connection with the receipt of Federal funds; School officials may verify the information on the application; and Deliberate misrepresentation of the information may subject the applicant to prosecution under State and Federal statutes.

Part 1: Children Information

List all household members

Anyone who is living with you and shares income and expenses, even if not related.

who are infants, children

Anyone age 18 or under and are supported with the household’s income; or in your care under a foster arrangement, or qualify as homeless, migrant, or runaway youth; or students attending high school grade 12 or under, regardless of age.

, and students up to and including grade 12

Migrant status is used only to determine eligibility for free or reduced price meals. We do not use this information for other purposes.

Child’s First Name * Middle Initial Last Name * Student Status Other Status (check all that apply)
Foster

A child who is formally placed by a court or a State child welfare agency.

Head Start

A child that is enrolled in a Federal Head Start or State-funded pre-kindergarten program that uses eligibility criteria that is identical or more stringent than Federal Head Start

Homeless / Migrant / Runaway
  • Homeless: A child identified by the Local Education Agency (LEA) homeless liaison or by an official of a homeless shelter as lacking a fixed, regular, and adequate nighttime residence.
  • Migrant: A child identified as a migrant by the State or local Migrant Education Program coordinator or the local educational liaison, or other individual identified by FNS (Food and Nutrition Service).
  • Runaway: A child identified as a runaway receiving assistance under a program under the Runaway and Homeless Youth Act, by the local educational liaison, or other individual in accordance with guidance issued by FNS.
First name is required Last name is required
Student Status
Other Status
  • Foster: A child who is formally placed by a court or a State child welfare agency.
  • Head Start: A child that is enrolled in a Federal Head Start or State-funded pre-kindergarten program that uses eligibility criteria that is identical or more stringent than Federal Head Start.
  • Homeless: A child identified by the Local Education Agency (LEA) homeless liaison or by an official of a homeless shelter as lacking a fixed, regular, and adequate nighttime residence.
  • Migrant: A child identified as a migrant by the State or local Migrant Education Program coordinator or the local educational liaison, or other individual identified by FNS (Food and Nutrition Service).
  • Runaway: A child identified as a runaway receiving assistance under a program under the Runaway and Homeless Youth Act, by the local educational liaison, or other individual in accordance with guidance issued by FNS.

CHILDREN’S RACIAL & ETHNIC IDENTITIES

Responding to this section is optional and does not affect your children’s eligibility for free or reduced price meals.

We are required to ask for information about your children’s race and ethnicity to make sure we are fully serving our community.

Ethnicity (check one)

Ethnicity

Race (check all that apply)

Race

Part 2: Assistance Programs

Indicate below if anyone in your household currently participates in SNAP, TANF, or FDPIR
  • SNAP: Supplemental Nutrition Assistance Program (formerly known as food stamps)
  • TANF: Temporary Assistance for Needy Families
  • FDPIR: Food Distribution Program on Indian Reservations

Based on the information you provided, you are not required to complete this section.

If your household participates in more than one assistance programs, please include only one of the case numbers below. It does not matter which one you choose to include.

If you’d like to learn more about these programs, take a look at the Food and Nutrition Services website.

Assistance Programs
  • Since you indicated that you receive assistance, we need your case number
This field is required

Part 3: Household Income

Report income for all household members (adults and children)

Based on the information you provided, you are not required to complete this section.

CHILD INCOME

Money received from outside your household that is paid directly to your children. Many households do not have any child income.

In part 1, you listed 1 child in your household.

For each child listed, if they receive income, report gross total income for each source in whole dollars only (before taxes and deductions). If there is no income to report, leave the amount at 0.

Bi-Weekly = every two weeks (26 paychecks a year).
2x A Month = twice a month (24 paychecks a year).

Child’s Name Income *
Earnings from Work + 

Salary or wages from a job.

Social Security Benefits + 

Social Security benefits for the child’s own blindness or disability, or because a parent is disabled, retired, or deceased.

Income from Other Household + 

Spending money or other income from a person outside the household such as an extended family member or friend.

Other Income

Income from any other source such as from a private pension fund, annuity, or trust.

  • Earnings from Work: Salary or wages from a job.
  • Social Security Benefits: Social Security benefits for the child’s own blindness or disability, or because a parent is disabled, retired, or deceased.
  • Income from Other Household: Spending money or other income from a person outside the household such as an extended family member or friend.
  • Other Income: Income from any other source such as from a private pension fund, annuity, or trust.

ADULT INCOME

List all household members not listed above (including yourself) even if they do not receive income.

Household members do not necessarily have to be your immediate family. For example, grandparents, cousins, or friends who live with you and share income and living expenses count as household members.

For each adult household member listed, if they receive income, report gross total income for each source in whole dollars only (before taxes and deductions). If there is no income to report, leave the amount at 0.

Bi-Weekly = every two weeks (26 paychecks a year).
2x A Month = twice a month (24 paychecks a year).

Adult’s First Name * Last Name * Income *
Earnings from Work + 
  • Salary, wages, cash bonuses
  • Net income from self-employment (farm or business)
  • Strike benefits

If you are in the U.S. Military:

  • Basic pay and cash bonuses (do NOT include combat pay, FSSA or privatized housing allowances)
  • Allowances for off-base housing, food, and clothing
Public Assistance/Child Support/Alimony + 
  • Unemployment benefits
  • Worker’s compensation
  • Supplemental Security Income (SSI)
  • Cash assistance from State or local government
  • Alimony payments
  • Child support payments
  • Veteran’s benefits
Pensions/Retirement/All Other Income
  • Social Security (including railroad retirement and black lung benefits)
  • Private pensions or disability
  • Income from trusts or estates
  • Annuities
  • Investment income
  • Earned interest
  • Rental income
  • Regular cash payments from outside household
First name is required Last name is required
$ Earnings amount is required (enter 0 if none)
Adult Earnings from Work Frequency
Please select a frequency for earnings
$ Assistance amount is required (enter 0 if none)
Adult Public Assistance Frequency
Please select a frequency for assistance
$ Pension amount is required (enter 0 if none)
Adult Pension Frequency
Please select a frequency for pension
My household has 0 members and earns $ 0 annually.

SOCIAL SECURITY INFORMATION

United States citizenship or immigration status is not a condition of eligibility for free and reduced price lunch benefits. Your children may still be eligible for this benefit even if you do not have a Social Security Number (SSN).

If more than one person in your household has a SSN, please include only one number below. It does not matter which one you choose to include.

Does the primary wage earner or another member in your household have a Social Security Number (SSN)?

Social Security Number
  • Since you indicated that you have a SSN, we need the last 4 digits of your SSNPlease make sure you enter a 4-digit number
SSN information is required

Part 4: Adult Contact Information

Provide your contact information

City is required
State is required
ZIP code is required
Phone number seems invalid; make sure it’s formatted properly (e.g. 312-456-7890)
Email seems to be invalid; make sure it’s formatted properly (e.g. name@mail.com)
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Part 5: Summary & Submit

Review your application before you submit it

ADULT SIGNER Edit

No name provided.
01/01/2016

CHILDREN INFORMATION Edit

No information entered.

ASSISTANCE PROGRAMS Edit

(Information not required)

No information entered.

HOUSEHOLD INCOME Edit

(Information not required)

My household has 2 members and earns $ 0 annually.
No SSN information entered.

Children Income
No information entered.
Adult Income
No information entered.

ADULT CONTACT INFORMATION Edit

No information entered.

Thank You!

Your application has been submitted and you don’t need to do anything further.

We will review your information and you will receive a letter in the mail if you are eligible for this benefit.

In the meantime, please contact John Doe at 123-456-7890 or john.doe@springfield.edu if you have questions.

Please review errors in this section
  • Section 1 of 5
  • Section 2 of 5
  • Section 3 of 5
  • Section 4 of 5
  • Section 5 of 5