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
➊ 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
➌ 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)
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 |
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 X—X X—
Return the completed application to: Waller ISD School Nutrition Services 1918 Key Street Waller Texas 77484, Fax: (936) 931-4047, email: rboleman@wallerisd.net , or to your child’s school.
StreetAddress APT# City State ZipCode PhoneNumber
Continued on back.
The Richard B. Russell Natonal 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 last four digits of the social security number of the adult household member who signs the application. The last four digits of 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.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877‐8339. Additionally, program information may be made availa‐ ble in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD‐3027) found online at: htps://www.usda.gov/oascr/how‐to‐file‐a‐program‐discrimination‐complaint, and at any USDA office, or write a leter addressed to USDA and provide in the leter all of the information requested in the form. To request a copy of the complaint form, call (866) 632‐9992. Submit your completed form or leter to USDA by:
mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW
Washington, D.C. 20250‐9410;
fax: (202) 690‐7442; or
This institution is an equal opportunity provider.