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.
Carefully read these instructions BEFORE completing the Application=
for
CNP Benefits!
To apply for Child Nut=
rition
Program benefits, complete all req=
uired
parts of the application using the instructions below. Return the application to the
school. All applications must=
be
signed. Call the school if yo=
u need
help.
·
·
·
Part 1. Children in School
a.&n=
bsp;
Write the la=
st
name, first name, school and grade of each student.
b.&n=
bsp;
If you get F=
ood
Stamps, Temporary Assistance to Families (TAF), or Food Distribution Progra=
m on
Indian Reservations (FDPIR) benefits, write the case number for each stu=
dent.
Part 2. Foster Child
a.&n=
bsp;
Check the bo=
x if
this application is for a child who is the legal responsibility of a welfare
agency or court. Complete a
separate application for each foster child. List information for only t=
he
foster child on the application.
b.&n=
bsp;
In Par=
t 3, list the foster child’s monthly “pe=
rsonal
use” income which is (1) money given by the welfare office for the
child’s personal use, identified by category such as for clothing, sc=
hool
fees, and allowances; and (2) all other money the child gets, such as money
from his/her family and money from his/her full-time or regular part-time j=
obs. If the child does not get
“personal use” income, mark the “Check if NO Income”
box.
Part 3. Gross Income for ALL Household Mem=
bers
a.&n=
bsp;
Write the na=
mes of
everyone in your household, whether they have income or not. Include the child(ren) you are app=
lying
for, all other children, your spouse, grandparents, and other related and
unrelated people in your household.
If you need more space, write the additional information on a piece =
of
paper and attach it to the application.
b.&n=
bsp;
In the
“Amount” column that best describes each income source (i.e.
Earnings, Other Regular Income, Temporary Income), write how much income ea=
ch
household member got for the last pay period before taxes or anything else =
is
taken out. See the list of in=
come
to report below.
c.&n=
bsp;
In the ̶=
0;How
Often” column, write how often each amount of income is received: Weekly, Every 2 Weeks, Twice a Mon=
th,
Monthly or Yearly.
d.&n=
bsp;
Check the
“Check if NO Income” box if a household member has no income.
Part 4. Children’s Racial & Ethn=
ic
Identities
Check
the ethnic identity(ies) and r=
acial
identity(ies) of your child(ren).
We need this information to be sure everyone gets benefits on a fair
basis. You do not have to pro=
vide
this information to get reduced price or free Child Nutrition Program benef=
its.
Part 5. Adult Household Member Information=
a.&n=
bsp;
Write the ad=
ult
household member’s name, e-mail address, mailing address, city, state,
zip code, home phone, employer(s) name and work phone.
b.
Write the So=
cial
Security number of the adult who will sign the application. If this adult does not have a Soci=
al
Security number, write “none”.=
A Social Security number is not needed if a Food Stamp, TAF or FD=
PIR
number is listed for each child or the application is for a foster child.
c.&n=
bsp;
The adult mu=
st
sign and date the application.
Incom=
e to
Report
|
Earnings |
Other Regular Income, continued |
Temporary or Occasional Income |
|
Wages,
salaries, tips, overtime pay |
SRS
cash assistance |
Strike
benefits |
|
Net
income from self-owned business or farm |
Alimony |
Unemployment
compensation |
|
|
Child
support payments |
Worker’s
compensation |
|
Other Regular Income |
Disability
benefits |
Interest/dividends |
|
Pensions,
retirement income |
Income
from estates/trusts/investments |
Cash
withdrawn from savings |
|
Social
Security income Veteran
payments |
Royalties/annuities/rental
income Regular
contributions from persons not living in |
Any
other income that may be available to pay for the child’s meals |
|
Supplemental
Security Income (SSI) |
the household |
|
Income From Self Employment:
Self-employed persons may use income tax records for the preceding
calendar year as a base to project the current year’s net income, unl=
ess
the current monthly income provides a more accurate measure. Report income derived from the bus=
iness
venture less operating costs incurred in the generation of that income. Deductions for personal expenses s=
uch as
interest on home payments, medical expenses, and other similar non-business
deductions are not allowed in reducing gross business income. Additional income from other kinds=
of
employment must be treated as separate and apart from the income generated =
from
your business venture. For ex=
ample,
if you operated a business at a net loss, but held additional employment for
which a salary was received, the income for purposes of applying for reduced
price or free meals would be the income from the salary only. The loss from the business cannot =
be
deducted from a positive income earned in other employment. For purposes of this application, =
it is
not possible to report a negative income from any business venture. The least income possible is zero =
(no
income).
The necessa=
ry
information for arriving at allowable income from private business operation
may be taken from your most recent U.S. Individual Income Tax Return - Form
1040. Add together the amounts
reported on the following lines:
=
&nb=
sp; =
&nb=
sp;
LINE 12 =
; $_______________ Business Income or (Loss)
=
&nb=
sp; =
&nb=
sp;
LINE 13 =
; $_______________ Capital Gain or (Loss)
=
&nb=
sp; =
&nb=
sp;
LINE 14 =
; $_______________ Other Gains or (Losses)
=
&nb=
sp; =
&nb=
sp;
LINE 17 =
; $_______________ Rental real estate, royalties,
partnerships, S corporations, trusts, etc.
=
&nb=
sp; =
&nb=
sp;
LINE 18 =
; $_______________ Farm Income or (Loss)
=
&nb=
sp; =
&nb=
sp;
TOTAL &=
nbsp; $_______________ Report annual income in Part 3.
Privacy
Act Statement – This explains how we will use the information you give
us.
The
Richard B. Russell National School Lunch Act requires the information on the
application for Child Nutrition Program Benefits. You do not have to give t=
he
information, but if you do not, we cannot approve your child for reduced pr=
ice
or free meals. You must inclu=
de the
Social Security number of the adult household member who signs the applicat=
ion. The Social Security number is not
required when you apply on behalf of a foster child or you list a Food Stamp
Program, Temporary Assistance for Families (TAF) Program or Food Distributi=
on
Program on Indian Reservations (FDPIR) case number or other FDPIR identifier
for your child, or when you indicate that the adult household member signing
the application does not have a Social Security number. We will use your information to
determine if your child is eligible for reduced price or free meals, and for
administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility infor=
mation
with education, health, and nutrition programs to help them evaluate, fund =
or
determine benefits for their programs, auditors for program reviews and law
enforcement officials to help them look into violations of program rules.
Page 1 - Form 3B – 05/07