DO NOT WRITE IN THIS AREA
SIGNATURE AND SOCIAL SECURITY NUMBER - Adult must sign (FIRMA Y NUMERO DE SEGURO SOCIAL - debe firmar un adulto)
MUST LIST PHONE CONTACTS (DEBE LISTAR CONTACTOS de TELEFONO):
6
5
Evening (Tarde)
-
-Day (Día)
-
-Other (Otro)
-
-Address (Dirección postal o de domicilio) Apt.
City (Ciudad) State (Estado) Zip Code (Código Postal)
ADDRESS AND PHONE (DIRECCION Y TELEFONO)
An ADULT household member MUST SIGN and include the last four digits of his/her SOCIAL SECURITY NUMBER above. Un adulto en el hogar DEBE FIRMAR e incluir los últimos 4-digitos del seguro social arriba.
2015 - 2016 FAMILY APPLICATION FOR MEAL BENEFITS
Duval County Public Schools
PRINT NEATLY (ESCRIBE CLARAMENTE CON LETRA DE MOLDE)Use BLUE or BLACK ink (Use tinta AZUL o NEGRA)
Complete ONE APPLICATION for ALL STUDENTS in the household. Complete UNA SOLICITUD para TODOS ESTUDIANTES en el hogar.
For faster service, complete online at: https://free-reduced-lunch.duvalschools.org
(Número de Identificación del Estudiante)Student ID Number
STUDENT'S INFORMATION - List ALL students attending Duval County Public Schools
Indique los estudiantes en escuelas de Duval County que viven con usted. Put an X for a New or PreK/K Student PreK/K New
1
(FOR OFFICE USE ONLY) (PARA USO DE LA OFICINA)
School Name
(Nombre de la Escuela) (Grado)Grade Student's Date of Birth
(Fecha de Nacimiento) / / / / / / / / / / / / Last
(Apellido) First(Nombre) (Inicial)MI
" X"if foster child "X" si hijo de crianza
Enter 10 Digit Number (DO NOT LIST CARD #) SNAP and TANF
(Formerly Food Stamp)
List the case number for ANY household member (including adults and children) receiving SNAP or TANF benefits.
(Liste el Número del caso para CUALQUIER miembro de su hogar (incluir adultos y niños) que recibe los beneficios de SNAP o TANF. PART 6GO TO
2
We e kly
STUDENT INCOME (Ingresos del Estudiante)
B i-We e kly
List amount and how often.
(Anote la cantidad y frecuencia) Mo nth ly 2 x M o nth ly "X" if NO Income W E T M W E T M W E T M W E T M W E T M W E T M ("X" si no ingresos)
.
$.
$ $.
$.
$.
$.
Email Date (Fecha)
/
/
No, I do not want school officials to share information from my application with Medicaid or FAMIS.
Households may request a hearing to appeal the application decision. Please call 732-5145 if you wish to appeal. Usted puede solicitor una audiencia para apelar la decision. Por favor llamar al 732-5145 si desea apelar.
.
$.
$.
$.
$.
$.
$ (Otros Ingresos) Other Income W E T M W E T M W E T M W E T M W E T M W E T M Bi-W ee kly / 2 Se ma na s We ekl y / Se ma na l 2 X Mo nth ly / Qu ince nal Mo nth ly / Ca da m es(Ingresos de Ayudas Sociales, Pensiones Infantiles o Pensiones Alimenticias)
.
$.
$.
$.
$.
$.
$Welfare / Child Support / Alimony B i-We ekl y / 2 S em an as W E T M W E T M W E T M W E T M W E T M W E T M We ekl y / Se ma na l 2 X Mo nth ly / Qu ince nal Mo nth ly / Ca da m es
.
$.
$.
$.
$.
$.
$ (Ingresos de Pensiones, Jubilación y Seguro Social)Pensions / Retirement / Social Security W E T M W E T M W E T M W E T M W E T M W E T M B i-We ekl y / 2 S em an as We ekly / S em ana l 2 X Mo nth ly / Qu ince nal Mo nth ly / Ca da m es INCOME SECTION
List ALL household members that are NOT students in PART 1.
Liste los nombres de todos los miembros de su Hogar; sin incluir los estudiantes en PARTE 1.
Last (Apellido) First (Nombre)
Check here if NO Income (Marque si no ingresos)
4
Mo nth ly / Ca da m es We ekly / S em an al 2 X Mo nth ly / Qu ince nal B i-We ekl y / 2 S em an asEarnings from work before deductions (Ingresos brutos (antes de impuestos))
,
.
$,
.
$,
.
$,
.
$,
.
$,
.
$ W E T M A W E T M A W E T M A W E T M A W E T M A W E T M A An nu ally / A nua lesHOMELESS, MIGRANT OR RUNAWAY
If Homeless, Migrant or a Runaway, no application is required. Contact DCPS Homeless Coordinators at 390-2528.
Si el niño para quien usted está llenando esta solicitud es un niño sin hogar, emigrante o un niño que ha abandonado su hogar, no se requiere solicitud. Llama 390-2528.
Homeless (sin hogar) Migrant (emigrante) Runaway (abandonó el hogar)
3
Si algún miembro familiar recibe ingresos, anotar la cantidad y frecuencia que recibe el pago. Si la persona no tiene ningún ingreso, marque "X" en el cuadro de no ingresos. how often that income is received. If the household member has no income, mark an "X" in the zero income box.
You must tell us HOW MUCH and HOW OFTEN. List EVERYONE in Household, regardless of income, EXCEPT THE STUDENTS who are listed above. If the household member has income, list the income amount and specify
**Only seasonal, migrant, or self-employed families are permitted to report income on an annual basis. Solo familias de temporada, emigrantes, o que trabajan por cuenta propia estan permitidas a reportar ingresos anuales.**
* * * *
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.
Yo certifico (prometo) que toda la información en esta solicitud es verdadera y que he puesto todos los ingresos. Entiendo que esta información se da en relación con el recibo de fondos federales y que funcionarios escolares pueden verificar (comprobar) la información. Tengo plena conciencia de que si deliberadamente doy información falsa, mis hijos pueden perder los beneficios de comidas y puedo ser enjuiciado según las leyes estatales y federales aplicables.
Social Security Number (Número del Seguro Social)
-
-X -X -X
X X
I do not have a Social Security Number No tengo un Número del seguro socialSignature of parent/guardian (Firma del padre/tutor) X
Parent/Guardian First Name (Nombre del padre/tutor) Parent/Guardian Last Name (Apellido del padre/tutor)
~ I N S T R U C T I O N S ~
2015 - 2016 FAMILY APPLICATION FOR MEAL BENEFITS
(Please use BLUE or BLACK ink only to complete the application)
An application for meal benefits can be completed online. Online applications can be processed more
quickly and easily than a paper application; electronic submission reduces application errors by
preventing the submission of applications with incomplete information. Go to:
https://free-reduced-lunch.duvalschools.org
and click on the link for the online application.
PART 1
List all students in household currently attending Duval County Public Schools. You must include last name,
first name, date of birth, name of the school the child will be attending, grade level and student income. Mark
an
(X)
in the box if the student is New (to Duval County), a Pre-Kindergartner or a Kindergartner. If the child
is a foster child, mark an
(X)
in the “if foster child” box (located in between the child’s name and date of birth).
A foster child is a child in the custody of a State or Local government agency. Foster children will receive free
meal benefits, regardless of the child’s income or the income of the household where they reside. They may
also be included as a member of the foster family if they choose to apply. If the foster family is not eligible for
free meals, it does not prevent the foster child from receiving benefits.
NO INCOME
: If a student in your household has no income, mark an
(X)
in the box for NO STUDENT
INCOME to the right of the student’s grade. Please list
gross
income for each student living in the household
including how much and how often, if applicable.
PART 2
If anyone in your household receives SNAP (Supplemental Nutrition Assistance Program) or TANF (Temporary
Assistance for Needy Families) benefits, list the case number for the person who receives benefits. This should
be a ten-digit number. Please do not use the Food Stamp or TANF card number. Households who are currently
members of the certified SNAP or TANF programs may skip to Part 6 after completing Part 2 when completing
a family application. Free meal eligibility due to SNAP/TANF extends to all children in a household.
PART 3
If your child can be considered “Homeless”, “Migrant” or a “Runaway” under the McKinney/Vento Act,
no
application is required
. Instead, contact the District Homeless Coordinator at 904-390-2528 for further
assistance.
PART 4
List everyone living in the household who is not a student currently attending a Duval County Public School.
Please list
gross income
for each member living in the household including how much and how often.
Only
seasonal, migrant, or self-employed families are permitted to report income on an annual basis.
NO INCOME
: If a member of your household has no income, mark an
(X)
in the box on the far right of the
page beside the household member’s name.
INSTRUCTIONS FOR HOUSEHOLDS WITH DEPLOYED SERVICE MEMBERS:
For the purpose of determining household size, families should include the names of the deployed service
members on their application. Report only that portion of the deployed service member’s income made
available to them or on their behalf to the family. The determining official would count the service member as
part of the household in establishing a child’s eligibility for free and reduced price meals. The Military Housing
Privatization Initiative
states that you do not include the housing allowance if you live in privatized government
housing.
PART 5
All applicants must complete this section, except for households reporting SNAP or TANF in part 2. The Free
& Reduced Price Meal Department may need to contact you for additional information. Incomplete applications
cannot be processed.
PART 6
Please print your name in the lower left-hand section of part 6 and then sign and date your application in the
lower right-hand section because it cannot be processed without a signature and the last
four
of the Social
Security number if required. (The last
four
social security numbers are not required if you receive SNAP or
TANF benefits.)
If your household qualifies for free or reduced-price meals, your students may be eligible to receive a state-supported scholarship to a private school. The program, called the Florida Tax Credit Scholarship, was created in 2001 and is run by a nonprofit, Step Up For Students. The scholarship is based on income and not on the academic performance of the student. The scholarship is worth more than $4,700 and can be used at about 1,500 private schools statewide; a separate $500 transportation scholarship is available to attend a public school in another county. In 2012-13, more than 50,000 students participated. For more information, visit www.StepUpForStudents.org, call 877-735-7837 or email
DEAR PARENT OR GUARDIAN,
Duval County Public Schools serves nutritious meals every school day. Students may buy lunch for $1.80 in Elementary Schools (grades PK-5) and $2.35 in Middle/High Schools (grades 6-12). Students may buy breakfast for $1.00 in Elementary Schools (grades PK-5) and $1.25 in Middle/High Schools (grades 6-12). Qualified students may also receive meals for free, or at a reduced-price of $0.30 for breakfast and $0.40 for lunch.
If you have received a NOTICE OF DIRECT CERTIFICATION for free meals, do not complete the application. But do let the school know if any children in your household are not listed on the Notice of Direct Certification letter you received.
To apply for free or reduced-price meals, please read the instructions for completing the 2015-2016 application on the next page of this document package. You can also complete the application for meal benefits online.
Go to https://free-reduced-lunch.duvalschools.org and click on the link for the online application for meal
benefits. Online applications prevent the submission of an incomplete application and are able to be processed quicker. See the front office personnel at your child’s school to access a District provided computer for completing
an online application. An application may not be necessary for your family if your child(ren) attend one of our Community
Eligibility Provision schools, where universally free meals are served to all students. (See the cover letter to this document package for more details.)
We cannot approve an application that is not complete, so please be sure to fill out all of the required information and
return it to your student’s school or fax the application directly to the Free and Reduced Department at 904-732-5157 located at 2924 Knights Lane East, Building #4, Jacksonville, FL 32216.
Please submit only ONE APPLICATION PER HOUSEHOLD!
Once you have been approved for benefits, they are good for the entire school year. However, the information on the application may be verified at any time during the year. If a household’s circumstances change, the household may apply for benefits at any time during the year. Children of parents or guardians who become unemployed may be eligible for free or reduced-price meals during the period of unemployment. WIC participants may also be eligible for free or reduced-price meals. Foster children are eligible for free meals regardless of the household income.
The Free and Reduced Department’s main number is 904- 732-5145. Please call this number if you have questions
regarding free or reduced-price meals. We are located at 2924 Knights Lane East, Building #4, Jacksonville, FL 32216. Households may request a hearing to appeal the application decision. Please call 904-732-5145 if you wish to appeal the decision. Si surge la necesidad por una applicacion en Espanol, el telefono de contacto es 904-732-5145.
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.
The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.)
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202)690-7442 or email at program.intake@usda.gov.
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service 800) 877-8339; or (800) 845-6136 (Spanish). All meals meet nutritional standards set by the US Department of Agricultural. If your child has a disability defined by the American Disability Act and that disability prevents your child from eating regular school meals, the school make any substitutions prescribed by a medical professional at no extra charge. The school is not required to make a substitution for a food allergy unless the allergy meets the definition of a disability. If you believe your child needs substitutions because of a disability, please contact the cafeteria manager at your child’s school for further information. USDA is an equal opportunity provider and employer.
FLORIDA INCOME ELIGIBILITY GUIDELINES
FOR FREE AND
REDUCED-PRICE MEALS
Effective from July 1, 2015, to June 30, 2016
REDUCED-PRICE MEAL SCALE
Household
Size
Annual
Monthly
Twice Per
Month
Every Two
Weeks
Weekly
1
21,775
1,815
908
838
419
2
29,471
2,456
1,228
1,134
567
3
37,167
3,098
1,549
1,430
715
4
44,863
3,739
1,870
1,726
863
5
52,559
4,380
2,190
2,022
1,011
6
60,255
5,022
2,511
2,318
1,159
7
67,951
5,663
2,832
2,614
1,307
8
75,647
6,304
3,152
2,910
1,455
For each
additional family
member, add
+ 7,696
+ 642
+ 321
+ 296
+ 148
“The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or if all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.)
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at
http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter
containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at
program.intake@usda.gov.
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (in Spanish).
“USDA is an equal opportunity provider and employer.” Dear DCPS Parent or Guardian:
We are pleased to inform you that Duval County Public Schools (DCPS) will continue to participate in an option available to schools participating in the National School Lunch and School Breakfast Programs called the Community Eligibility Provision (CEP) program for School Year 2015-2016. Schools that participate in the CEP program are able to provide healthy breakfasts and lunches each day at no charge to ALL students enrolled in a CEP school during the 2015-2016 school year. If your children attend one of the following schools, they will be included in this program:
A PHILLIP RANDOLPH FORT CAROLINE MDDLE LEE ROBERT E HIGH RIBAULT SENIOR
ANDREW A. ROBINSON ELEM FRANK PETERSON HIGH LONE STAR ELEM RUFUS PAYNE ELEM
ANNIE R MORGAN ELEM GARDEN CITY ELEM LONG BRANCH ELEM RUTH N UPSON ELEM
ARLINGTON ELEM GEORGE W CARVER ELEM LOVE GROVE ELEM RUTHLEDGE PEARSON ELEM
ARLINGTON HEIGHTS ELEM GRAND PARK LONG BRANCH ELEM SA HULL ELEM
ARLINGTON MIDDLE GREENFIELD ELEM MAMIE AGNES JONES ELEM SADIE TILLIS ELEM
BAYVIEW ELEM GREGORY DRIVE ELEM MARTIN LUTHER KING ELEM SALLYE B MATHIS ELEM
BEAUCLERC ELEM HENRY F KITE ELEM MATTHEW GILBERT MIDDLE SAN JOSE ELEM
BILTMORE ELEM HIGHLANDS ELEM MAYPORT ELEM SOUTHSIDE ESTATES ELEM
BISCAYNE ELEM HIGHLANDS MIDDLE MERRILL ROAD ELEM SOUTHSIDE MIDDLE
BRENTWOOD ELEM HOGAN SPRING GLEN ELEM MT. HERMAN EXCEPTIONAL SP LIVINGSTON ELEM
BRIDGE THE HOLIDAY HILL ELEM NORMANDY VILLAGE ELEM SPRING PARK ELEM
BROOKVIEW ELEM HYDE GROVE ELEM NORTHSHORE ELEM ST CLAIR EVANS ACADEMY
CARTER G WOODSON ELEM HYDE PARK ELEM NORTHWESTERN MIDDLE STONEWALL JACKSON ELEM
CEDAR HILLS ELEM JACKSON ANDREW HIGH OAK HILL ELEM SUSIE TOLBERT ELEM
CENTRAL RIVERSIDE ELEM JACKSONVILLE HEIGHTS ELEM OCEANWAY ELEM TERRY PARKER HIGH
CHIMNEY LAKES ELEM JEB STUART MIDDLE ORTEGA ELEM THOMAS JEFFERSON ELEM
CROWN POINT ELEM JEFF DAVIS MIDDLE PALM AVENUE EXCEPTIONAL
STUDENT CENTER TIMUCUAN ELEM
CRYSTAL SPRINGS ELEM JOHN E FORD K8 PARKWOOD HEIGHTS ELEM VENETIA ELEM
DINSMORE ELEM JOHN LOVE ELEM PICKETT ELEM WEST JACKSONVILLE ELEM
DON BREWER ELEM JOSEPH STILWELL MIDDLE PINE ESTATES ELEM WEST RIVERSIDE ELEM
DUPONT MIDDLE JUSTINA ROAD ELEM PINEDALE ELEM WESTSIDE HIGH
ED WHITE HIGH JWJ ACTC R.L. BROWN ELEM WESTVIEW K8
ENGLEWOOD ELEM KERNAN TRAILS ELEM R.V. DANIELS ELEM WHITEHOUSE ELEM
ENGLEWOOD HIGH KINGS TRAIL ELEM RAINES HIGH WINDY HILL ELEM
ENTERPRISE LEARNING ACADEMY LAKE FOREST ELEM RAMONA ELEM WOLFSON HIGH
EUGENE BUTLER MIDDLE LAKE LUCINA ELEM REYNOLDS LANE ELEM WOODLAND ACRES ELEM
FORT CAROLINE ELEM LAKESHORE MIDDLE RIBAULT MIDDLE
A Free and Reduced Meal Application is not required if all of your school-aged children attend a CEP program participating school listed above. If you have a child that attends one of the schools above, but another that attends a school not listed above or all of your children attend a school not listed above, you will need to complete a free and reduced meal application that includes all of your children if you desire to qualify for free or reduced meal benefits. An application can be completed online at: https://free-reduced-lunch.duvalschools.org. A paper version may also be located at the above website, obtained from your child’s school or contact the Food Service Department at 904-732-5145. Please do not hesitate to contact our office if we can assist you further.
