2020-2021 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

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

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.         

2.         

3.         

4.         

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).

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)

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.


1.

$

W-E-T-M-A

$

W-E-T-M-A

$

W-E-T-M-A

$

W-E-T-M-A

2.

$

W-E-T-M-A

$

W-E-T-M-A

$

W-E-T-M-A

$

W-E-T-M-A

3.

$

W-E-T-M-A

$

W-E-T-M-A

$

W-E-T-M-A

$

W-E-T-M-A

4.

$

W-E-T-M-A

$

W-E-T-M-A

$

W-E-T-M-A

$

W-E-T-M-A


TOTAL HOUSEHOLD MEMBERS (CHILDREN & ADULTS)

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

Child Name Weekly Every 2 Weeks Twice per Month Monthly Annually

1.

$

$

$

$

$

2.

$

$

$

$

$

3.

$

$

$

$

$


SIGNATURE 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 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)

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

XX XX X

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.


StreetAddress APT# City State ZipCode PhoneNumber

    