SCHOOL DISTRICT OF ELMBROOK
Food Service, PO Box 1830
Brookfield WI  53008-1830

(262)781-3030 x1148

 

INSTRUCTIONS FOR APPLYING

Use a separate application for each foster child.  List other children together.

FOOD SHARE OR W-2 cash benefits

Part 1: List child(ren)'s name, school, grade, and a FoodShare or W-2 cash benefit number.  A FoodShare or W-2 number must be filled in for each child receiving benefits.

DO NOT LIST:  Forward or Quest Card, Medicaid, SSI, W-2 Childcare case numbers or Social Security Numbers

Part 2: Skip this part.

Part 3: Skip this part.

Part 4: Sign the form. A Social Security Number is not necessary.

Part 5: Answer this question if you choose to. 

For Public Schools Only

If you are applying for a child that is Homeless, Migrant or a Runaway, please contact your school, homeless liaison or migrant coordinator. 
FOSTER CHILD
Part 1: Use a separate application for each foster child. List the child's name, school, and grade.
Part 2: Check the box and list the child's personal use monthly income, if any.
Part 3: Skip this part.
Part 4: Sign the form. A Social Security Number is not necessary.
Part 5: Answer this question if you choose to.

KINSHIP HOUSEHOLDS

In cases where no specific child welfare or court is legally responsible for the child, the child is considered to be a member of the household with whom he or she resides.  All income received by the household, including public assistance, must be reported by the household and used to determine eligibility.  KINSHIP HOUSEHOLDS must complete Parts 1, 3 and 4.

ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:

Part 1: List each child's name, school, and grade.

Part 2: Skip this part.

Part 3: 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 any other children not listed in Part 1. 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 4: 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 5: Answer this question if you choose to.

MATERIAL FEE WAIVER - PLEASE FILL OUT & RETURN THE ATTACHED "SHARING INFORMATION" SHEET 

Privacy Act 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, 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 list a FoodShare or W-2 cash benefit number 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.