Norwalk: NSLP Application

Norwalk - YCSC: Application for Free and Reduced-Price Meals (NSLP)

Complete one application per household.
Please read the instructions on how to apply. This institution is an equal opportunity provider. California Education Code Section 49557(a): Applications for free and reduced-price meals may be submitted at any time during a school day. Children participating in the federal National School Lunch Program will not be overtly identified by the use of special tokens, special tickets, special serving lines, separate entrances, separate dining areas, or by any other means.
STEP 1-STUDENT INFORMATION
Children in Foster Care and children who meet the definition of Homeless, Migrant, or Runaway are eligible for free meals.

STEP 1 - STUDENT INFORMATION: Enter for each student living in the household

Rows	Full Name of Each Student (EXAMPLE: Joseph P Adams)	Enter School Name of Each Student (Ex: Lincoln Elementary)	Grade Level of Each Student (Ex: 9th)	Enter each student's birth date (Ex: 12-15-2010)	Check the box if the student is a Foster Youth	Check the box if the student is a Homeless Youth	Check the box if the student is a Migrant Youth	Check the box if the student is a Runaway Youth
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2
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4

STEP 2 - ASSISTANCE PROGRAMS: CalFresh, CalWORKs, or FDPIR
Do ANY household members (child or adult) currently participate in CalFresh, CalWORKs or FDPIR?
If you answered NO to the previous question, you can skip this step, scroll down, and click the "Next" button to move on to STEP 3.

If you answered YES, complete the section below.
Select Program Type:
Enter Case Number:

STEP 3-REPORT INCOME FOR ALL HOUSEHOLD MEMBERS
If you answered YES in the previous step (you receive CalFresh, CalWORKS or FDPIR), you may scroll down and click the NEXT button to move onto the next step. If you answered NO in the previous step, you must complete this section.

A. STUDENT INCOME: Sometimes students in the household earn income. Enter the TOTAL GROSS income (before deductions) in whole dollars earned by all students listed in STEP 1.
Total Student Income (earned by ALL students listed in Step 1)
Ex: $10,000
How often? (W = Weekly, 2W = Bi-weekly, 2M = Twice Monthly, M = Monthly, Y = Yearly)
B. ALL OTHER HOUSEHOLD MEMBERS (induding yourself):

List ALL household members not listed in STEP 1, even if they do not receive income.

For each household member, report the TOTAL GROSS income (before deductions) in whole dollars for each source.

If the household member does not receive income from any sources, write "0". If you enter "0" or leave any fields blank, you are certifying (promising) that there is no income to report.

Enter the appropriate pay period in the "How Often" box:

W = Weekly

2W = Biweekly

2M = Twice a Month

M = Monthly

Y = Yearly

List ALL household members not listed in STEP 1, even if they do not receive income. For each household member, report the TOTAL GROSS income (before deductions) in whole dollars for each source. If the household member does not receive income from any sources, write "0". If you enter "0" or leave any fields blank, you are certifying that there is no income to report. Enter the appropriate pay period in the "How Often" box: W = Weekly, 2W = Biweekly, 2M = Twice a Month, M = Monthly, Y = Yearly

Rows	Type the name of ALL OTHER Household Members (First and Last)	Earnings from Work	How Often?	Public Child Assistance/SSI/ Support/Alimony	How Often	Pensions/Retirement/ Other Income	How Often ?
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Total Household Members (Children and Adults)
D. Enter the last four digits of Social Security number (SSN) from the Primary Wage Earner or Other Adult Household Member
Check below if there is no Social Security Number for the Primary Wage Earner

STEP 4-CONTACT INFORMATION & ADULT SIGNATURE
Certification: I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted under applicable state and federal laws.

NOTE: The Adult Student or Primary Adult Wage Earner will be required to sign the completed form by hand. After the counselor or site staff receive your submission, they will print it out and have you sign it. Your form is not complete until you sign it by hand.
Print Name:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number:
Format: (000) 000-0000.
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail:
example@example.com

OPTIONAL-CHILDREN'S ETHNIC AND RACIAL IDENTITIES

If you do not wish to answer these questions, please scroll down and click the SUBMIT button.
We are required to ask for information about your children's race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children's eligibility for free or reduced-price meals.
Ethnicity (check one):
Race (check one or more):
Should be Empty:

Norwalk - YCSC: Application for Free and Reduced-Price Meals (NSLP)

STEP 1-STUDENT INFORMATION

STEP 2 - ASSISTANCE PROGRAMS: CalFresh, CalWORKs, or FDPIR

STEP 3-REPORT INCOME FOR ALL HOUSEHOLD MEMBERS

STEP 4-CONTACT INFORMATION & ADULT SIGNATURE

OPTIONAL-CHILDREN'S ETHNIC AND RACIAL IDENTITIES