Free & Reduced Lunch Application Form

DOHN COMMUNITY HIGH SCHOOL
608 E. McMillan Street  Cincinnati, Ohio 45206
Phone:   281-6100   Fax:  281-6103
Dear Parent/Guardian:
Children need healthy meals to learn. Dohn Community High School offers healthy meals every school day. Breakfast costs $1.50; lunch costs $2.50. Your children may qualify for free meals or for reduced price meals. Reduced price is .25 for breakfast and .25 for lunch.
1. Do I need to fill out an application for each child?  No. Complete the application to apply for free or reduced price meals. Use one Free and Reduced Price School Meals Application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to: Dohn Community High School, 608 E. McMillan Street, Cincinnati, Ohio, 45206.
2. Who can get free meals? Children in households receiving benefits through the Food Assistance Program (SNAP, formerly the Food Stamp Program), or Ohio Works First (OWF) benefits and most foster children can get free meals regardless of your income. Also, your children can get free meals if your household income is within the free limits on the Federal Income Guidelines.
3. Can homeless, runaway and migrant children get free meals? Please call Pieter Elmendorf at
281-6100 to see if your child(ren) qualify, if you have not been informed that they will get free meals.
4. Who can get reduced price meals? Your children can get low cost meals if your household income is within the reduced price limits on the Federal Income Chart, shown on this application.
5. Should I fill out an application if I got a letter this school year saying my children are approved for free or reduced price meals? Please read the letter you got carefully and follow the instructions. Call the school at 281-6100 if you have questions.
6. I get WIC. Can my child(ren) get free meals? Children in households participating in WIC may be eligible for free or reduced price meals. Please fill out an application.
7. Will the information I give be checked? Yes, we may ask you to send written proof.
8. If I don’t qualify now, may I apply later? Yes. You may apply at any time during the school year if your household size goes up, income goes down, or if you start receiving Food Assistance Program (SNAP) benefits or getting OWF or other benefits. If you lose your job, your children may be able to get free or reduced price meals.
9. What if I disagree with the school’s decision about my application? You should talk to school officials. You also may ask for a hearing by calling or writing to: Kenneth J. Furrier, 608 E. McMillan Street, Cincinnati, Ohio, 45206, 281-6100.
10. May I apply if someone in my household is not a U.S. citizen? Yes. You or your child(ren) do not have to be a U.S. citizen to qualify for free or reduced price meals.
11. Who should I include as members of my household? You must include all people living in your household, related or not (such as grandparents, other relatives, or friends). You must include yourself and all children who live with you.
12. What if my income is not always the same? List the amount that you normally get. For example, if you normally get $1000 each month, but you missed some work last month and only got $900, put down that you get $1000 per month.  If you normally get overtime, include it, but not if you get it only sometimes. 
13. We are in the military, do we include our housing allowance as income? If your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. All other allowances must be included in your gross income.
 
If you have other questions or need help, call 281-6100.
 
Sincerely,
 
 
 
Kenneth J Furrier
INSTRUCTIONS FOR APPLYING
If your household receives benefits from the Food Assistance Program (SNAP, formerly the Food Stamp Program), or gets Ohio Works First (OWF), follow these instructions:
Part 1: List child(ren)’s name, school, grade, and a 10 digit SNAP (Food Stamp) or OWF case number beside each child’s name.  Ohio Direction Card Numbers are not acceptable (these are 16 digits in length).
Part 2: Check the appropriate box, if any.
Part 3: Skip this part.
Part 4: Skip this part.
Part 5: Sign the form. A Social Security Number is not necessary.
Part 6: Answer this question if you choose to.
 
Check the appropriate box and contact Pieter Elmendorf at 281-6100.
Fill out application by following instructions for ALL OTHER HOUSEHOLDS.
 
If you are applying for a FOSTER CHILD, follow these instructions:
Part 1: Use a separate application for each foster child. List the child’s name, school, and grade.
Part 2: Skip this part.
Part 3: Check the box and list the child’s personal use monthly income, if any.
Part 4: Skip this part.
Part 5: Sign the form. A Social Security Number is not necessary.
Part 6: Answer this question if you choose to.
 
ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:
Part 1: List each child’s name, school, and grade.
Part 2: Check the appropriate box, if any.
Part 3: Skip this part.
Part 4: Follow these instructions to report total household income from last month.
Column 1–Name: List the first and last name of each person living in your household, related or not (such as grandparents, other relatives, or friends). You must include yourself and all children living with you. Attach another sheet of paper if you need to.
Column 2 –Gross income last month and how often it was received.  Next to each person’s name list each type of income received last month, and how often it was received.  For example, Earnings from work:  List the gross income each person earned from work.  This is not the same as take-home pay.  Gross income is the amount earned before taxes and other deductions.  The amount should be listed on your pay stub, or your boss can tell you.  Next to the amount, write how often the person got it (weekly, every other week, twice a month, or monthly).  All other income:  List the amount each person got last month from welfare, child support, alimony, (second column) pensions, retirement, Social Security (third column), and ALL OTHER INCOME SOURCES (fourth column).  In the All Other column, include  Worker’s Compensation, unemployment, strike benefits, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), disability benefits, regular contributions from people who do not live in your household, and ANY OTHER INCOME.  Report net income for self-owned business, farm, or rental income.  Next to the amount, write how often the person got it. If you are in the Military Housing Privatization Initiative do not include this housing allowance.
Column 3–Check if no income: If the person does not have any income, check the box.
Part 5: An adult household member must sign the form and list his or her Social Security Number, or mark the box if he or she doesn’t have one.
Part 6: Answer this question if you choose to.
2009-2010 FREE AND REDUCED PRICE SCHOOL MEALS FAMILY APPLICATION
Part 1. Children in School (Use a separate application for each foster child)
Names of all children in school
(First, Middle Initial, Last)
School Name
Grade
10-digit Food Assistance Program* (SNAP, Food Stamp) or OWF case # (if any) for each child. Skip to Part 5 if you list a SNAP* or OWF case #
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Part 2. If the child you are applying for is homeless, migrant, or a runaway check the appropriate box and call Pieter Elmendorf at 281-6100.                                 Homeless  q  Migrant q  Runaway  q
Part 3. Foster Child
If this application is for a child who is the legal responsibility of a welfare agency or court, check this box q and then list the amount of the child’s personal use monthly income:  $__________. Skip to Part 5.
Part
4. Total Household Gross Income—You must tell us how much and how often
1. Name
(List everyone
in household)
2. Gross income and how often it was received
Example:   $100/monthly   $100/twice a month    $100/every other week   $100/weekly
3. Check
if NO income
Earnings from work before deductions
Welfare, child support, alimony
Pensions, retirement, Social Security
All Other Income
(Example)
Jane Smith
$200/weekly_____
$150/weekly_____
$100/monthly_____
$______/________
q    
 
$______/________
$______/________
$______/________
$______/_______
q    
 
$______/________
$______/________
$______/________
$______/_______
q    
 
$______/________
$______/________
$______/________
$______/_______
q    
 
$______/________
$______/________
$______/________
$______/_______
q    
 
$______/________
$______/________
$______/________
$______/_______
q    
 
$______/________
$______/________
$______/________
$______/_______
q    
 
$______/________
$______/________
$______/________
$______/_______
q    
 
$______/________
$______/________
$______/________
$______/_______
q    
Part 5. Signature and Social Security Number (Adult must sign)
An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on the back of this page.)
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.    
Sign here: X______________________________Print name:_____________________________Date: ______________ 
Address:_______________________________________________________Phone Number:______________________
Social Security Number:  __ __ __ - __ __ - __ __ __ __    q I do not have a Social Security Number
Part 6. Children’s ethnic and racial identities (optional)
Choose one ethnicity:
Choose one or more (regardless of ethnicity):                                                   
q Hispanic/Latino
q Not Hispanic/Latino
 
q Asian                                   q American Indian or Alaska Native                                                         
q White                                   q Native Hawaiian or other Pacific Islander                            
q Black or African American  
Don’t fill out this part. This is for school use only.
Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24 Monthly x 12
Total Income: ____________ Per: q Week, q Every 2 Weeks, q Twice A Month, q Month, q Year       Household size: ________
Categorical Eligibility: ___  Date Withdrawn: ________Eligibility: Free___  Reduced___  Denied___ Reason: ________________________
Temporary: Free_____  Reduced_____  Time Period: ___________ (expires after _____ days)
Determining/Approval Official’s Signature: ________________________________________________ Date: ______________
Confirming Official’s Signature: __________________ Date: _______ Follow-up Official’s Signature: __________________ Date: ________
If selected for Verification, Date Verification Notice Sent:_______ Response Date: _______ 2nd Notice Sent: _______ Results Sent:_______
Verification Result:  No Change _____  Free to Reduced Price _____ Free to Paid _____ Reduced Price to Free _____ Reduced Price to Paid _____
 
 
FEDERAL INCOME CHART
For School Year 2009-2010
Household size
Yearly
Monthly
Weekly
1
20,036
1,670
386
2
26,955
2,247
519
3
33,874
2,823
652
4
40,793
3,400
785
5
47,712
3,976
918
6
54,631
4,553
1,051
7
61,550
5,130
1,184
8
68,469
5,706
1,317
Each additional person:
6,919
577
134
Your children may qualify for free or reduced price meals if your household income falls within the limits on this chart.
 
 
 
 
 
 
 
 
 
* SNAP: Food Assistance Program (formerly the Food Stamp Program)
 
 

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 this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals.  You must include the social security number of the adult household member who signs the application.  The social security number is not required when you apply on behalf of a foster child or you list a Food Assistance Program (SNAP, former Food Stamp Program), Ohio Works First (OWF) Program or Food Distribution 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 free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information 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.
 
 

Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. “In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (800) 795-3272 or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.”
SHARING INFORMATION WITH MEDICAID/Healthy Start, Healthy Families
 

Dear Parent/Guardian:
If your children get free or reduced price school meals, they may also be able to get free or low-cost health insurance through Medicaid or the State of Ohio Healthy Start, Healthy Families Program.  Children with health insurance are more likely to get regular health care and are less likely to miss school because of sickness.
Because health insurance is so important to children’s well-being, the law allows us to tell Medicaid and Healthy Start, Healthy Families that your children are eligible for free or reduced price meals, unless you tell us not to. Medicaid and Healthy Start, Healthy Families only use the information to identify children who may be eligible for their programs. Program officials may contact you to offer to enroll your children (Filling out the Free and Reduced Price School Meals Application does not automatically enroll your children in health insurance).
If you do not want us to share your information with Medicaid or Healthy Start, Healthy Families, fill out the form below and send in (Sending in this form will not change whether your children get free or reduced price meals).
 
 

q   No! I DO NOT want information from my Free and Reduced Price School Meals Application shared with Medicaid or the Healthy Start, Healthy Families.
 
If you checked no, fill out the form below.
 
Child's Name: _______________________School:________________________            
Child's Name: _______________________School:________________________
Child's Name: _______________________School:________________________
Child's Name: _______________________School:________________________
Signature of Parent/Guardian: ____________________________Date: _______
Printed Name:____________________ Address:_________________________
For more information, you may call Pieter Elmendorf at 281-6100.
Return this form to: 608 E. McMillan Street, Cincinnati, Ohio  45206 within 5 days of receiving application.