2018-2019 Family Application for Meal Benefits                                                                   Waller Independent School District                                       DATE COMPLETED: __________________________

Read the instructions on the back of this form. Use black or blue ink. Print neatly within the boxes. Complete only ONE application per household. OR you may apply ONLINE at www.mealappnow.com/manwal

For assistance with this form call, 936.931.2347               

Œ IF ANYONE IN THE HOUSEHOLD HAS AN ELIGIBILITY GROUP NUMBER FOR SNAP OR TANF WRITE THE EDG NUMBER IN THE SPACES    ¨¨¨¨¨¨¨¨¨

v Students in household: Fill out the information below for ALL STUDENTS  currently enrolled in Waller ISD schools.  For any student that is a foster child, homeless, migrant or runaway, please check the box below.

                                                                                                                                                                                                                                                                                

        Student I.D. Number                   FIRST Name                                           LAST Name                                Grade                                            School Name                 Foster           Homeless         Migrant       Runaway                                                                                                                                                                                                                                                                                                                           

1.  00000 0000000000 0000000000 00 000000000000 0  0  0  0

2.   00000 0000000000 0000000000 00 000000000000 0  0  0  0

3.   00000 0000000000 0000000000 00 000000000000 0  0  0  0

4.   00000 0000000000 0000000000 00 000000000000 0  0  0  0

5.  00000 0000000000 0000000000 00 000000000000 0  0  0  0

6.  00000 0000000000 0000000000 00 000000000000 0  0  0  0

Ž IF THE HOUSEHOLD HAS AN EDG NUMBER, SKIP THIS PART.

   HOUSEHOLD MEMBERS: Include ALL other household members and their  income., if they have any.  List gross income before taxes and deductions. You do not have to list students that are already listed above.

              In the frequency box, HOW OFTEN IS INCOME RECEIVED? Using the following, please indicate in the box under FREQUENCY; (W = weekly, E= every two weeks, T= twice a month, M= Monthly, and A= Annually).

              Putting a zero (0) in any income box, or leaving it blank, indicates that person has NO INCOME, and you are certifying (promising) this is correct information.

     

                  Print first and last name of other                          Income from Work          Frequency                  Welfare Payments,   Frequency            Income from pensions              Frequency                                  Frequency                           

                        Household members.                                    Before deductions         (circle one)               Child Support/Alimony        (circle one)             Retirement, Social Security        (circle one)                 All other income          (circle one) 

TOTAL HOUSEHOLD MEMBERS (CHILDREN & ADULTS) ______

 

COMBINED INCOME FOR CHILDREN IN THE HOUSEHOLD (DO NOT INCLUDE ADULT INCOME):

 

 Weekly $___________   Monthly $______________ Every 2 weeks $______________  Twice a Month $_______________ Annually $_________________ 

 

xSIGNATURE SECTION     I certify (promise) that all of the information on this application is true and that all income is reported. I understand that the school  y SOCIAL An adult household member must provide the last 4                            

                                                       will get Federal funds based on the information I give. I understand that school officials may verify (check) this information.                      SECURITY #:  of their Social Security # or mark the “NO SSN” box. 

                       I understand that if I purposely give false information, my children may lose meal benefits and I may be prosecuted under state and federal statues.          (See privacy Statement on the back side of this form)

First Name (print)                                                                              Last Name (print)                                                 Formal Signature                                                                                            Last 4 digits of SSN            If No SSN check this box 

          X XX X0000                               

Return the completed application to: Waller ISD School Nutrition Services 1918 Key Street Waller Texas 77484, Fax: (936) 931-4047, email: mwarzon@wallerisd.net , or to your child’s school.                                                                                                                                                                                                                                                                                                                                                         

              Street Address                                                                                                                                                                                                             APT #                             City                                                                                                            State                 Zip Code                                         Phone Number

000000000000000000000000 000000000000000000 000000000000000                                                                        

 

  

 

 

 

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