Dear Parent/Guardian:
Children need healthy meals to learn. Lincoln County School Dist. #2 offers healthy meals every school
day. Breakfast costs $1.00 K-6/$1.25 7-12; lunch costs $2.00 K-6/$2.25 7-12. Your children may qualify for
free meals or for reduced price meals. Reduced price is $.30 for breakfast and $.40 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: LCSD #2, Attn: Lunch Program, P0 Box 219, Afton,
WY 83110 307-885-7137.
2. Who can get free meals? Children in households receiving Supplemental Nutrition Assistance Program
(SNAP) benefits (formerly the Food Stamp Program), or getting TANF, 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 Mark Taylor 307-885-
7138, school homeless liaison 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 307-885-
7137 if you have questions.
6. I get WIC. Can my child(ren) get free meals? Children in households participating in WIC Jy be eligible for free
or reduced puce 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 SNAP or getting TANF 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: Jon Abrams, P0 Box 219, Afton, WY
83110, 307-885-3811.
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 307-885-7137.
Si necesita ayuda, por favor Ilame a! teléfono: 307-885-7137.
Si vous voudriez d’aide, contactez nous au numero: 307-885-7137.
Sincerely,
Free and Reduced Price School Meals Application 2010-2011
Letter to Households
Page 1 of 2
INSTRUCTIONS FOR APPLYING
If your household receives benefits from the Supplemental Nutrition Assistance Program (SNAP),
formerly the Food Stamp Program, or gets TANF, follow these instructions:
Part 1: List child(ren)’s name, school, grade, and a SNAP or TANF case number.
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 Mark Taylor, homeless liaison, migrant coordinator at 307-885-
3178.
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.
Free and Reduced Price School Meals Application 2010-2011
Letter to Households
Page 2 of 2
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Your children may qualify FEDERAL INCOME CHART
for free or reduced price For School Year 2009-2010
meals if your household Household size Yearly Monthly Weekly
income falls within the 1
limits on this chart. $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: $6919 $577 $134
*
SNAP: Supplemental Nutrition 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 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.
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.”
Free and Reduced Price School Meals Application 2010-2011
Application
Page 2 of 2
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SHARING INFORMATION WITH OTHER PROGRAMS
Dear Parent/Guardian:
To save you time and effort, the information you gave on your Free and Reduced Price
School Meals Application may be shared with other programs for which your children
may qualify. For the following programs, we must have your permission to share
your information. Sending in this form will not change whether your children get
free or reduced price meals.
IJ No! I DO NOT want information from my Free and Reduced Price School Meals
Application shared with any of these programs.
Li Yes! I DO want school officials to share information from my Free and Reduced
Price School Meals Application with
Li Yes! I DO want school officials to share information from my Free and Reduced
Price School Meals Application with
Li Yes! I DO want school officials to share information from my Free and Reduced
Price School Meals Application with
If you checked yes to any or all of the boxes above, fill out the form below. Your
information will be shared only with the programs you checked.
Child’s Name:
Child’s Name:
Child’s Name: School:
Child’s Name:
Signature of Parent/Guardian: Date:
Printed Name:
Address:
For more information, you may call 307-885-7137.
Return this form to: LCSD #2, P0 Box 219, Afton, WY 83110 immediately.
Free and Reduced Price School Meals Application 2010-2011
Sharing Information with Other Programs
Page 1 of I
Would you like information about Health Insurance for your Children?
Many families who work hard to make ends meet can get FREE or low cost health insurance for
their children.
In fact, families who qualify for the school lunch program usually qualify for either Kid Care
CHIP or EqualityCare, Wyoming’s free and low cost health plans.
Simply return this completed form with your school lunch application and we will send you
some information and an application for Kid Care CHIP and EqualityCare. Or just give us a call
at 1-877-KIDS NOW (1-877-543-7669).
ere
Printed Name of Parent/Guardian:
Mailing Address (or P0 Box):
City, State, Zip Code:
County:
Phone Number:
Name of School:
Do your children currently have health insurance? Yes No (please circle one)
If yes, name of company or program:
(Kid Care CHIP, EqualityCare, Medicaid, Title 19, BlueCross BlueShield, Great West, WinHealth, etc.)
School Personnel:
Please return this form to Kid Care CHIP, 6101 Yellowstone Rd. Suite 210, Cheyenne, WY
82002.
Revised 2/2007