Section 1. Check the box if this is the first time that you have applied for meal benefits for any of your children at this school district or nonpublic school.
- List all children in the household, including foster children, and provide the requested information for each child. Birthdate, School, and Grade are not required fields.
- Foster children: check the "foster child" box for each child who is a foster child (a welfare agency or court has legal responsibility for the child). If all children who need to be approved for school meal benefits are foster children, skip sections 2 and 3.
Section 2. If any member of the household receives public assistance from any of the following three programs, provide the person's name and case number: Minnesota Family Investment Program (MFIP), Food Support (SNAP), or Food Distribution Program on Indian Reservations (FDPIR). If section 2 is completed, skip section 3. A Medical Assistance number does not qualify for this purpose.
Section 3. Provide all household members and all incomes. List any regular incomes to children such as SSI payments or regular earnings. Do not list occasional earnings like babysitting. Include all adult persons who live in the household whether related or not. Also include any persons who are temporarily away, such as a student away at college.
- For earnings, list gross income before taxes and other deductions, not take home pay. You should be able to find your gross income on your pay stub. For farm/self-employment income only, list net income after business expenses. Provide how often each income is received: Weekly (W), Bi-Weekly (every other month) (BW), Twice per Month (TM), or Monthly (M). Do not Provide an hourly wage.
- Examples of "other income" to include in the last column are farm or self-employment income, Veterans (VA) benefits, and disability benefits.
- Do not include as income: foster care payments, federal education benefits, or assistance provided by MFIP, Food Support (SNAP), WIC or FDPIR. Military: Do not include income from the Military Privatized Housing Initiative or combat pay.
Section 4. The form must be signed by an adult household member. If section 3 of the application has been completed, the signer must provide the last four digits of their Social Security Number unless they indicate that they do not have a Social Security Number. Provide address and phone number to assist in processing your application.
Section 5. Leave these boxes blank if you want to share your school meal eligibility status with these health benefit/insurance programs. Check the boxes if you do not want to share your eligibility status with these programs.
Section 6. Please provide voluntary racial/ethnic information.