Free and Reduced Lunch Application

This is an application to enroll your child in a free or reduced lunch program.

You do not need to create an account.

You can finish the application in one sitting.

If you have to leave, your information will be saved on your browser
and you can resume at any time.

Begin
 Use of Information Statement

Before we begin, theres a statement we have to include.

A summary
In order to approve your child for free or reduced price meals,
you need to submit all needed information in this application. You will need
the following information:
- last four digits of SSN of the adult household member who signs the application
- if you do not have SSN, you can still submit the application
- a case number for SNAP, TANF or FDPIR, if you are enrolled in any such program

Full Text
Use of Information Statement
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 submit all needed
information, we cannot approve your child for free or reduced price meals. You must include
the last four digits of 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 Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance
for Needy Families (TANF) 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.

Next
 USDA Non-Discrimation Statement
USDA has tried to make the application process open to
as many people as possible. If you feel you need special
assistance, you can contact the USDA through the
Federal Relay Service at (900) 877-8339.
USDA Non-Discrimination Statement
In accordance with Federal civil rights law and U.S. Department of Agriculture
(USDA) civil rights regulations and policies, the USDA, its Agencies, oces, and
employees, and institutions participating in or administering USDA programs are
prohibited from discriminating based on race, color, national origin, sex, disability,
age, or reprisal or retaliation for prior civil rights activity in any program or activity
conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for

program information (e.g. Braille, large print, audiotape, American Sign Language,
etc.), should contact the Agency (State or local) where they applied for benefits.
Individuals who are deaf, hard of hearing or have speech disabilities may contact
USDA through the Federal Relay Service at (800) 877-8339. Additionally, program
information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program

Discrimination Complaint Form, (AD-3027) found online at: http://
www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA oce, or write a
letter addressed to USDA and provide in the letter all of the information requested
in the form. To request a copy of the complaint form, call (866) 632-9992. Submit
your completed form or letter to USDA by:

(1) Mail: U.S. Department of Agriculture

Oce of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;

(2) Fax: (202) 690-7442; or

(3) Email: program.intake@usda.gov.

This institution is an equal opportunity provider.

Next
 Dev notes: I think
we should not use
+/- because user
Pre-Application Survey would have to hit
enter after clicking.
To help us prepare your application, please fill out this form.
Remember, you only need one application per family.
Dev notes: The Dev notes: Add a
grey line indicates hint to input text.
1) How many adults are in your household? (Include yourself)
that the next
*Hint: Most applicants include grandparents and relatives. 3
question only
Applicants benefit from reporting this information correctly. Type in your answer
appears after the
first one has been
answered. 2) How many children living in your household are 18 years
2
old or younger?
*Hint: Include all children, even if they are unrelated to you
and are supported by your income.
3) Do you have any children who are over 18 years old but Yes/No
attending 12th grade or lower?
[if YES] 3b) How many? 1

Dev notes: For Q4,

fill in blank with 4) Of your ___ children, how many of your children are
1
sum of Q2 + foster children?
Q3(b).
5) Do you have any children who are homeless, migrant, or Yes/No
runaway?

5b) How many of your children are homeless, migrant, or

0
runaway?

Dev notes: Fill in

6) I confirm that the total number of children in my household is _____. the blank with sum
*Hint: Includes your children from Question 2, Question 3, and Question 5. of Q2+Q3b+Q5b.

7) Please select all that apply.

Dev notes: If answer to Q6
==1, then:
- Change text of first option:
My child is blind or has a
disability. At least one of my children is blind or has a disability.

My child has a parent who is blind or has a disability,

Dev notes:

1) To see how this form works, go to www.healthsherpa.com. Enter the Zip

Code 90024 and click see plans and prices.

Back Save and Continue

 My Children Dev notes: The
grey line indicates
that the next
question only
My Children appears after the
first one has been
Dev notes: When user enters answered.
First Name and Last Name,
Child #1 replace Child #1 title with the
Names.

First Name Last Name

Dev notes:
Replace the blank Yes
1) Is ____ a student?
with the first name.
No

Dev notes: If Q4 2) Select all that apply to ___First Name___.

==Q6 from the
Pre-app survey,
then set Foster Foster Child
Child radio button
to Yes.
Homeless, migrant, or runaway

Head Start

3) Does your child have a disability? Yes

No

Dev notes:1) Repeat additional forms for more children. Total number of child
forms == answer to Q6 from pre-app survey.

Child #2 - Remove Child

+ Add Child

Dev notes: Only

when user checks
the box, does the
I have included all children in my household for this Save & Continue
section. Button become
enabled.

Previous Section Save and Continue

Dev notes:
Create a variable called Special_Status. We will reference this variable on the
next screen.

For each child, if any number of boxes is checked for Q2, Special_Status +=1.
Example: for Child #1, if Foster Child and Head Start is checked, only add 1 to
Special_Status.
 Childrens Racial &
Ethnic Identitities
We are required to ask for information about your childrens race and
ethnicity. This information is important and helps to make sure we are
fully serving our community. Responding to this section is optional and
does not affect your childrens eligibility for free or reduced price meals.

Dev notes:
Child #1 (Use their First Name Last Name) Pull data from My
Children page.
Ethnicity (Select 1)
* Your answer is optional
Dev notes:
1) make the
Hispanic or Latino interaction like
virginamerica.
Not Hispanic or Latino

Race (Check one or more)

* Your answer is optional Dev notes:
1) For the
checkbox
American Indian or Alaskan Native interaction, check
out http://
designmodo.githu
Asian b.io/Flat-UI/ .

Black or African American

Native Hawaiian or Other Pacific Islander

White

Do your remaining children belong to the same ethnic and -select-

racial groups?
Dev notes:
Dev notes: If user selects
If user selects No, Yes, then populate
then populate the the number of
number of child child forms based
Child #2 (Use their First Name Last Name) forms based on on Q6 from pre-
Q6 from pre-app app survey with
survey. race & ethnicity
above..
Previous Section Save and Continue

Dev notes:
Upon clicking Save & Continue:

If Special_Status == Q6 from Pre-App Survey, then skip to Contact Information

& Signature Page.
 Adults and Income

This is where you list all the adults in your household.

Adult #1
Your Name

Dev notes: If user First Name Last Name

selects this box,
skip to end of
section to the Select this box you do not have any income.
Confirmation
Statement.
Income from Work
Directions: Do not include income from self-employment.

Does __First Name___ earn a salary or wages from work? Yes No

How often?
Enter Amount. $0.00
Weekly

Bi-Weekly (twice a week)

Twice a month

Monthly

+ Add salary or wages from another job Dev notes: When

user hovers over
+ Add income from cash bonus
Continue button,
+ Add income from Strike Benefits change button
+ Add income from unemployment insurance color to Blue and
+ Add other earned income text to white.

Continue

Income from Self-Employment

If you have net income any of the following, sources, please add them.
*Hint: How to calculate net income: Gross receipts or revenue minus
operating expenses.
+ Add net income from Farm Income
+ Add net income from Partnership Income
+ Add net income from Professional Practice
+ Add net income from Other Self-Employment Sources

Continue

Income from the Military

Does __First Name___ serve in the US Military? Yes No

Dev notes: If No, continue to the next section. If Yes, show the following.

Please add income earned from the military. Do not report combat
pay, FSSA, or privatized housing allowances.
Military basic pay or cash bonuses
How often?
Enter Amount. $0.00
Weekly

Bi-Weekly (twice a week)

Twice a month

Monthly

Military allowances for off-base housing, food, or clothing

Enter Amount. $0.00 How often?

Weekly

Bi-Weekly (twice a week)

Twice a month

Monthly

Income from Other Sources

+ Add income from Public Assistance
+ Add income from Alimony
+ Add income from Child Support

Continue

Income from Retirement or Disability

+ Add income from Social Security
+ Add income from Railroad Retirement
+ Add income from Pensions
+ Add income from Annuities
+ Add income from Survivors Benefits
+ Add income from disability benefits from SSI
+ Add income from private disability benefits
+ Add income from black lung benefits
+ Add income from workers compensation
+ Add income from veterans benefits
+ Add income from other related sources

Continue

Income from Investment or Other Sources

+ Add income from Interest
+ Add income from Dividends
+ Add income from Trusts or Estates
+ Add income from Rental Income
+ Add income from Royalties
+ Add income from Prize Winnings
+ Add income from Money Withdrawn from Savings
+ Add income from Regular Contributions from friends or family
outside of the household

Continue

I confirm that to the best of my knowledge, I have reported income

accurately for __First Name Last Name__. If I did not add income
for any source, I certify that there is no income to report.
Dev notes: User
must click on
check box.
Clicking check box
triggers Continue
button to appear.
Continue

Dev notes:1) Repeat additional forms for more adults, depending on the
answer to Q1 in the pre-application survey.

Does the Primary Wage Earner or Other Adult Household Yes No

Member have a Social Security Number?
*Hint: Its ok to select No. Your children will be still be elgible for
benefits.

Dev notes:1) If user selects Yes, show the following.

Please enter last four digits of the

Social Security Number (SSN) for XXX XX 1234
the Primary Wage Earner or Other
Adult Household Member

Previous Section Save and Continue

 Childrens Income
Dev notes: If no income
selected, the form fields
should populate with
Child #1 (Show Name) zero. Then collapse. If
user adds a value to any
Income Sources field, the box becomes
unchecked.
Select this box, if child earns no income.

Income from Work

Does __First Name___ earn a salary or wages from work? Yes No
How often?
Enter Amount. $0.00
Weekly

Bi-Weekly (twice a week)

Twice a month

Monthly

+ Add salary or wages from another job

Dev notes: When user makes a selection, the Frequency form should collapse. Example
below.

Dev notes: User

Amount clicks edit >>
Every 2 weeks Edit
$200.00 expands the radio
button choices

Income from SSI

Does __First Name___ receive income from SSI for a disability? Yes No

*Note: You indicated that __First Name__ has a disability on the section My Children.
To change your answer, click here.
Dev notes: If answer to Q3 for this child from the page My Children == Yes, auto-select
the choice Yes. If answer to Q3 == No, auto-select No.

Does __First Name___ receive income from SSI because Yes No

a parent is disabled/retired/deceased?
Dev notes: If Q7-3rd choice is selected from the page Pre Application Survey == Yes,
auto-select the choice Yes.

Dev notes: If Yes, save this answer choice like this. Other children may receive SSI from
the same parent, so we want to avoid duplicating.

SSI from __First Name__s Parent

Amount
Every 2 weeks Edit
$200.00

Income from Other Sources

If __First Name__ recieves income from any of the following sources, please
click to add that information.
UX notes:
+ Add income from a private pension fund Consider adding
hints about what
+ Add income from an annuity these income
sources are.
+ Add income from a trust

Dev notes: When user adds any of the above, the form should look like this.

Income from a private pension fund

Amount
Every 2 weeks Edit
$200.00
Income from an annuity
Amount
Every 2 weeks Edit
$200.00

Income from Family or Friends

Does __First Name___ receive spending money or Yes No
income from someone outside of the household such as
a friend or other family member?
+ Add income from another person outside of the household

Total Monthly Income of First Name Last Name

Confirm

Dev notes: Math time. Calculate the following.

For each income item, do the following:

Income_item_monthly_total = Income Item Amount x Multiplier.

If Weekly, Multipler == 4
else if biweekly, Multiplier == 8
else If every 2 weeks, Multiplier == 2
else if monthly, Multiplier ==1

Monthly_total_income = sum of all income_item_monthly_total

Child #2 (Show Name)

Previous Section Save and Continue

 Benefits and Assistance Programs

Some households have members who are enrolled in public assistance programs.

Select the program that applies to your household. Leave blank if they do
not apply to you.

Check all that apply. Dev notes: If User

*Hint: SNAP the Supplemental Nutrition Assistance Program. checks any of the

SNAP It is the food benefits program, formerly known of the boxes, then
as The Food Stamp Program. The exact name depends on your state. Trigger the Case
Number question.

TANF *Hint: TANF is Temporary Assistance for Needy Families.

FDPIR *Hint: FDPIR is the Food Distribution Program on Indian Reservations.

Please enter your Case Number.

*Hint: Because someone in your household receives benefits, you have a case
number. You can find your case number by reviewing benefits documents or
contacting your case worker.

Dev notes: Case Number should only appear if the user selects Yes for any of
the above choices.

Previous Section Save and Continue

Dev notes: Im thinking of a way for users to get help if they do not know this
information. For example, for all the questions that they dont know the answer
to, they can send an email to their social worker.

How can we help?

 Application Review
Your application is 100% complete.
Please take a moment to review your application.
If everything looks OK, click next.

Dev notes: Im thinking when they click on

Section 1: Pre-Application Survey
Section 2: Children in Household
Section 2-2: Childrens Race and Ethnicity
a section, it just expands with the key
information for a quick review.
If needed, they can also be taken to the
page to edit the info.

Section 3: Benefits & Assistance Programs

Section 4-1: Adults & Income

Section 4-2: Childrens Income

Previous Section Next

Dev notes: This page should give a summary of the users information for
review. If user has not finished their application, this page is inactive.
 Contact Information and Adult Signature
Dev notes: See form on
www.virginamerica.com
Pick a flight, Guest Checkout,
Contact Information of Adult Completing this Form and scroll to Complete Guest
Information.

First Name Last Name

Street Address (if available) Apt # (if available)

City State Zip

Daytime Phone Number (optional) Email Address (optional)

Back Continue

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 recipt of Federal funds, and that school officials
may verify (check) the information. I am aware that if I purposely give
false information, my children may lose meal benefits, and I may be
prosecuted under applicable State and Federal laws.

Type Signature Here

*Hint: Type your name if you agree with the
statement above.

Todays Date
Dev notes: Date autopopulated.

Submit Application
 Contact Information and Adult Signature
Dev notes: See form on
www.virginamerica.com
Pick a flight, Guest Checkout,
Contact Information of Adult Completing this Form and scroll to Complete Guest
Information.

First Name Last Name

Street Address (if available) Apt # (if available)

City Once you submit, you will no longer

State be able Zip
to edit your application.

Do you wish to submit?

Daytime Phone Number (optional) Email Address (optional)

Back Continue

No, Cancel. Yes, Submit.

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 recipt of Federal funds, and that school officials
may verify (check) the information. I am aware that if I purposely give
false information, my children may lose meal benefits, and I may be
prosecuted under applicable State and Federal laws.

Type Signature Here

*Hint: Type your name if you agree with the
statement above.

Todays Date
Dev notes: Date autopopulated.

Submit Application