2015-16 Greene County Schools Free and Reduced Price School Meals Household Application     (Complete one application per household.  Please use INK.

301 Kingold Blvd., Snow Hill, NC 28580, 252-747-3425                                                                                                                                             if more space is needed to list household members, attach a separate sheet of paper)                                                                                                                                                                                                                                                                                                                                                                 

ENTER Name of each Household Member

(First Middle Initial Last) and CIRCLE each individual’s role in the household.

 

HH = Head of Household

S = Student

O = Other family member

**PLEASE PRINT LEGIBLE**

For each STUDENT in the household please ENTER the Code of the School where student is currently enrolled and current Grade.

(if applicable)

SCHOOL CODES:

GC=Greene Central MS=Middle School

EC=Greene Early CollegeWG=West Greene

SHP=Snow Hill Primary PK=Pre-K Center

IS=Intermediate School FL=Family Literacy

If applicable,

please CIRCLE if a STUDENT is:

 

H = Homeless

M = Migrant

R = Runaway

F = Foster

INCOME 1) For households receiving assistance benefits, please SKIP to the SNAP/FNS, TANF, or FDPIR section below.

2) For EACH household member ENTER Income amount received and the code for the frequency (ex. $250.00|M).3) Use full dollar amounts (ex. $455.50).4) IMPORTANT NOTE: If an individual receives income from multiple sources in a category, enter the combined total of income for that category.

Work Income Earnings

(before deductions)

Welfare

Child Support

Alimony

Pensions

Retirement

Social Security/SSI

VA benefits

All

Other Income

NO Income

if

applicable, check the box

Name

Circle One:

School Code/Grade

NCWISE Number

(office use only)

Circle one:

Income Frequency Codes:Wk = WeeklyBiW = Bi-Weekly M = Monthly

BiM = Bi-Monthly A = Annually

 

FirstMILast

Income

Code

Income

Code

Income

Code

Income

Code

 

HH S O

 

 

H M R F

 

 

 

 

 

 

 

 

¨

 

HH S O

 

 

H M R F

 

 

 

 

 

 

 

 

¨

 

HH S O

 

 

H M R F

 

 

 

 

 

 

 

 

¨

 

HH S O

 

 

H M R F

 

 

 

 

 

 

 

 

¨

 

HH S O

 

 

H M R F

 

 

 

 

 

 

 

 

¨

 

HH S O

 

 

H M R F

 

 

 

 

 

 

 

 

¨

 

HH S O

 

 

H M R F

 

 

 

 

 

 

 

 

¨

 

SNAP/FNS, TANF or FDPIR Assistance Benefits            Households with a SNAP/FNS(FNS, formerly known as the Food Stamp program), TANF, or FDPIR recipient do not have to fill out the household income section, nor does the adult signing the application have to include the last 4 digits of their social security number.

If any member of your household receives SNAP/FNS, FDPIR or TANF/ Work First, please select the program type and provide the case number for the person who receives benefits.

Select program type:

¨ SNAP/FNS ¨ FDPIR ¨ TANF/Work First

CASE NUMBER: ____________________________

 

Attestation: An adult household Member must sign the application. If the income section 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 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 child(ren) may lose meal benefits and I may be prosecuted under State and Federal Laws.”

Head of Household Signature:

Printed Name:

Today’s Date:

Email:

Address:

City

State

Zip

Contact No:

Enter LAST FOUR DIGITS of Social Security number:XXX - XX

 

 

 

 

¨ I do not have a Social Security Number

 

Child(ren)’s Ethnic and Racial Identities (optional)

Select one ethnicity: ¨ Hispanic/Latino

¨ Not Hispanic/Latino

Select one or more (regardless of ethnicity):

¨ Asian ¨ American Indian or Alaska Native ¨ Black or African American

¨ White ¨ Native Hawaiian or other Pacific Islander

 

For Office Use Only

Annual Income Conversion: Weekly (x52) Bi-Weekly (x26) Monthly (x12) Bi-Monthly (x24)

Total Household Income ______________________ ¨ Weekly ¨ Bi-Weekly ¨ Monthly ¨ Bi-Monthly ¨ Annually Total Household Members ¨¨

Categorical Eligibility ­­­­­­­­­­­_________ Date Withdrawn:­­­­­__________ Eligibility:¨ Free ¨ Reduced ¨ Denied Reason: _________________________________________

Determining Official’s Signature:

Date:

Confirming Official’s Signature:

Date:

Verifying Official’s Signature:

Date: