Duval County Public Schools
FAMILY APPLICATION FOR FREE & REDUCED-PRICE MEALS
School Year 2016 - 2017
PART 1. Homeless, Migrant and Runaway Children
If you are applying for a child that is homeless, migrant or runaway please check the appropriate box.
PART 2. SNAP/TANF (Formerly Food Stamps)
If you have a SNAP, TANF, or Medicaid case number please enter the number here:
Please note, a valid case number contains only 10 digits and begins with 10,11,12, 13, 14 or 15 EX. 1200305555
PART 3. Student Information (Use paper application for more than six(6) students)
Date of Birth
Is the student listed above a Foster Child?
PART 4. Social Security Number and Guardian Information
An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list the last four digits of his or her Social Security Number or mark the “I do not have a Social Security Number” box.
I do not have a SSN
Guardian First Name
Guardian Last Name
Guardian SSN (last 4 digits)
PART 5. Total Household Income from last month (You must list ALL INCOME to qualify)
Total Number of Household Members
Check if no Income
Howmuch money did each person in the household make last month?
(W) Weekly (E) Every 2 weeks (T) Twice a Month (M) Monthly (A) Annual
List everyone in the household including students listed above.
Earning from Work before deductions
Welfare, Child Support, Alimony
Social Security, Pension, Retirement
Only self employed or seasonally employed individuals may report annual income. Indicate your status below
Seasonal or Migrant Employment
The information you have given on this Free and Reduced Price School Meals Application may qualify your child for additional programs and services. For the following programs, we must have your permission to share your information. Selecting this option will not change your child's status for receiving free or reduced price meals.
I would like the information on this application to be used in determining my child’s eligibility for the following programs.
College and Post-Secondary Scholarships and Application Waivers
Florida Kids Care
Medicaid & Health Insurance
Medicaid & Health Insurance: Your child may be eligible for other benefits. The school is allowed to share the information on this application with Medicaid. If you do not want this information shared you must tell us by checking the NO block below.
Your decision will not affect your child's eligibility for free or reduced price meals.
No, I do not want school officials to share information from my free or reduced price meal application with Medicaid or FAMIS.
PART 6. Digital Signature and compliance affirmations.
YOU MUST ACCEPT BOTH STATEMENTS FOR YOUR APPLICATION TO BE PROCESSED
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.
By my electronic submission of this application I verify my understanding/agreement with the above statement and all USDA guidelines regarding the Free and Reduced School Lunch Program.
Reviewed By (School Use Only)