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

First Name

Last Name

Student ID

School/Campus

Grade

or Status

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.

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

Other Income

First Name

Last Name

Sharing Information

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.

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.

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