m B DEPARTMENT OF EDUCATION ion for Educational Benefits 9 names, attach another sheet of p02. efor fee meals. Read How to Complete the Application for Educational rit or charter/nonpublic schools, return an application at eaeh one. ALL Household Members wh ‘A Household Member is “Aner inthe same housshold should be reported in Ste Grade Birthdate Chis Las Name lowing assistance programs: SNAP, MFIP or FOPIR? Medial reports cardmumber)— rity participate in one or more of th Number (between 49 dhs, do step if you answered Ys’ 1 STEP 2) STEP 2: Do Any Household Members including you WYES>nter SNAP, MFIP oF STEP 3: Report Income for ALL Household Members A tast Four Digits of Social ecurty Number (sh) of dul Household Member oxxx-L_] lor checkit adutthas No SSN: L_] Total Number of All Household Members (Chilren + Adis) 8. Child come, ies children nthe household ear o rece income, such froma parttime ob or SSL. Please ince the Sometimes renin the Howse . has fom art ime ob ot Ircuse ‘otal ncome Received by Acitren | Weekly | Biweekly | 2Month | Monthy sted in STEP 1 Do notincude income received by adits inthe box tothe right. ‘TOTAL Income received by a o a a a come fromany source, write” or leave any mation. "Sources of Income” wl help you ‘Members including youre). For each Household Member Iited,ifhey do receive income, report total gross Income oly they donot receiv Fels blank, You ace cetiying (promising) tat there no income to report. Not sue what income to include ere? Fp the page andreview “Sources of Income” wth the Chisncome secon ang Al Adit Howse Member sein. Tames oflAdul Household Members Ft and Last) Grom tarnngs om Working a0bs "re you sethemployed ora Farmer? ‘ny Other Goes nome =] =] amotnomenone | |> Netincome fom =] S|] a] SSivremetormen & | & | feporincome belo EB) =| tarmorsett #/ 3/52 Assistance, 2\5 5 |B) empormenoone | | 2) 2) 2) S| chesompor. an a duplicate elsewhere. a) a others on Page 2 ole ool ojalolols | ofo ofols alofolals olo a [ols afolalals ofa o [ols ofojalols formation on this plato itrue and that ll ncomelreperted. understand ve Inconnecon wih the rect of ju awaretet gis a verted? — yp tae anar’ ndat Donot Fit out: For school office use |B) S| S| 3] %| ~ aman — owe vera voee ae ‘Conversions to Analg Al income me “oo “oo ‘Minnesota Heh Care Program ae lowed by stat ? ——E>sS ageley Hie} F] 2 ‘ete ame of a sigigForm aptime Phone AN Total income EV EVE 2] 2] ome | $3) F] og] 8 {include child and adult income} = Sine: ‘asress vate) nm ly Z oistoloto ote Tol o Determining Of Signature: Date: SGN WERE: Signature of owehod A Owe Confiing Of Sigatue: Date: ‘se Page 2 fr Aditional information Rturn completed form tothe schol a theses iste atthe top ofthe form. Do not malo the Minnesota Deparment of Education or United States Department of AgricultureOPTIONAL: Children’s Racial and Ethnic identities Weare required to formation about your ehlren’ affect your eidre or fee or reduced price me ca and eth information important and helps to make sure we: Respond to both Step One, Ethnicity and Step Two, Race. Serving our community. Responding sections optional nd doesnot step One: Etniity (checkone): [7] wispanieor tating [7] not wispani or tating step Two: Race (check one or more: ] american inion lskan native C1] asan C1] atsckoratican American [] native Hawai o other INSTRUCTIONS: Sources of Income Sources of income for Children _ Sources of Income for Adults Sources of Child income cxamples All other come > = Aha has 9 req fal or parm job where they > Salary wages, cash bonuses before [+ = . fearna slay or wages deductions o 2. Disability Payments . . ‘+ supplemental seeuty income | 1B. Survvor'sgenefts + Unemployment bene + Incomefrom person outside | . Worker's compensation . thehousehala . + evestmentincome ‘+ Incomefrom anyother source | © . + Rental income : Regular ash payments : fromoutside| pension fund, annuity, or trust 1b. Allowances for oft-base housing, houwehala food 3d clothing yu donot, we cant approve your child for fee or reduced price meals You must “The Richard 8, Russell National School Lunch Act requires the information on tis application. You donot have to give the information, bi Ilo the information requested inthe for. To request a capy ofthe complain orm, cll Office ofthe Assistant Secretary fr Chi Rights 4400 independence Avenue, SW. Washington 0.¢. 20250-9410; (2) fax 202-680-7482; or (8) mai: rogamintake@usda.tow, This institlonis an equal opportuity provider.