MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01C85391.C05490B0" This document is a Single File Web Page, also known as a Web Archive file. If you are seeing this message, your browser or editor doesn't support Web Archive files. Please download a browser that supports Web Archive, such as Microsoft Internet Explorer. ------=_NextPart_01C85391.C05490B0 Content-Location: file:///C:/2284B2F3/2008_Form_3B_Application_withoutoptionalbenefits.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" School Year 2005-2006 Application for Child Nutrition Program Benefi= ts

School Year 2007-2008 Application = for Child Nutrition Program Benefits

Carefully follow instructions on page 2 of application.  An incomplete application cannot be approved.  Return completed application to school. =

Part 1. Children in School - Use a separate application for each foster chil= d.  If you enter a case number for E= ACH child in Part 1, go to Part 4.

 

Las= t Name

 

Fir= st Name

 

Sch= ool Name

 

Gra= de

Cas= e Number for

Food Stamps, TAF or FDPIR

1.=          = ;

 

 

 

 

2.=          = ;

 

 

 

 

3.=          = ;

 

 

 

 

4.=          = ;

 

 

 

 

5.=          = ;

 

 

 

 

Part 2. Foster Child   <= /span> FFFFFFFF650000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000  C= heck the box if this application is for a child who is the legal responsibility of= a welfare agency or court. 

       &nbs= p;      List his/her monthly personal use income in Part 3.<= span style=3D'mso-spacerun:yes'>  If the foster child has no perso= nal use income, check the “Check if NO Income” box.

Part 3. Gross Income= for ALL Household Members – Write the amount of gross income received and h= ow often it is received:  Weekl= y, Every 2 Weeks, Twice a Month, Monthly, Yearly.  See instructions on page 2 of application for income to report.

 

 

 

Lis= t Names of ALL

Hou= sehold Members

Ear= nings

Before Deductions

from Last Pay Period

(including Overtime)

Oth= er Regular Income:

SRS Cash Assistance,

Child Support, Alimony, Pension,

Social Security Income, Other

Tem= porary Income:

Strike Benefits,  Unemployment,

Worker’s Comp.

 

Check

If NO

Income

Amo= unt

How= Often

Amo= unt

How= Often

Amo= unt

How= Often

1.=         = ;

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FFFFFFFF650000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000

2.=         = ;

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FFFFFFFF650000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000

3.=         = ;

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FFFFFFFF650000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000

4.=         = ;

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FFFFFFFF650000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000

5.=         = ;

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$&= nbsp;      <= span style=3D'font-size:9.0pt'> 

 

FFFFFFFF650000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000

6.=         = ;

$&= nbsp;      <= span style=3D'font-size:9.0pt'> 

 

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$&= nbsp;      <= span style=3D'font-size:9.0pt'> 

 

FFFFFFFF650000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000

7.=         = ;

$&= nbsp;      <= span style=3D'font-size:9.0pt'> 

 

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$&= nbsp;      <= span style=3D'font-size:9.0pt'> 

 

FFFFFFFF650000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000

8.=         = ;

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$&= nbsp;      <= span style=3D'font-size:9.0pt'> 

 

FFFFFFFF650000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000

9.=         = ;

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10.     = ;

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FFFFFFFF010000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000

Part 4= . Children’s Ethnic Identity (op= tional) – Check one.    Children’s Rac= ial Identity (optional) – Check one or more.

FFFFFFFF650000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000  Hispanic or Latino       &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            FFFFFFFF650000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000  American Indian or Alaska Native        FFFFFFFF650000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000  Asian     FFFFFFFF010000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000  Black or African American

FFFFFFFF650000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000  Not Hispanic or Latino         &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;    FFFFFFFF650000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000  Native Hawaiian or Pacific Islander      FORMCHECKBOX FFFFFFFF650000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000  White     FFFFFFFF650000001400060043006800650063006B0032000000000000000000= 00000000000000000000000000000000  Other

Part 5. Adult Household Member Information=

Print Name_____________________________________= ____________________________   E-mail ______________________________________

Address, City, State, Zip ______________________________________________________   Home Phone  ________________________________<= o:p>

Employer(s) ___________________________________= _____________________________   Work Phone _______________= __________________

An adult household member must sign the application.  If Part 3 is completed, the adult signing the form must also provi= de his/her Social Security number OR if the adult does not have a Social Security number, write “none”.  See the Privacy Act Stateme= nt on page 2 of this application.

I certify that all information on this application is true and that all income is reported.<= span style=3D'mso-spacerun:yes'>  I understand that (1) the school= will receive Federal and State funds based on the information I give; (2) scho= ol officials may verify the information; and (3) if I purposely give false information, my child(ren) may lose meal benefits and I may be prosecuted= .

Sign Here X _______________________________________   Social Security Number  _________ - ______ - ___________=    Date: ___________       &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;         

FOR SC= HOOL USE ONLY.  DO NOT WRITE BELO= W.

Annual Income Conversion:  Weekly x 52, Ev= ery 2 Weeks x 26, Twice a Month x 24, Monthly x 12

Application Type (check one) 

<= span style=3D'font-size:8.0pt'> F= ood Stamps/TAF/FDPIR

<= span style=3D'font-size:8.0pt'> I= ncome Household – Total income:    $___________________= _

       &nbs= p;            &= nbsp;           &nbs= p;        Monthly Income OR  Annual Income

       &nbs= p;            &= nbsp;           &nbs= p;      Household size:       &nbs= p;      _______

<= span style=3D'font-size:8.0pt'> F= oster Child – Annual personal use income:  $______________