LIBERTYVILLE Dr. Prentiss Lea Superintendent HIGH SCHOOL Dr. Thomas Koulentes Principal Dear Parent or Guardian, Attached is an application for a basic fee waiver and free or reduced lunch for your student. Please fill out both sides of the application completely and return it along with verification of income (for example, copies of your two most recent pay stubs, a food stamp number, or last year s income tax form). Be sure to list all household members, including all children, even if they do not attend LHS. Salary information and wage verification must be included for every wage-earner in the household. Send the completed Fee Waiver Application and wage verification back to the high school with your student s registration materials. A separate Fee Waiver application must be completed for each child attending LHS to be processed. Please refer to the guidelines attached to help you determine whether or not to apply for these benefits. These guidelines are set up by the government to determine eligibility for the program. We wish you a pleasant summer and look forward to seeing your student in the fall. Sincerely, Thomas Koulentes Principal
DO YOU QUALIFY? Libertyville High School offers a program to provide a Basic Fee Waiver and free or reduced lunch for students of families in need. To help you determine whether or not to apply for these benefits, here are the guidelines set up by the government to determine eligibility for the program: REDUCED PRICE MEALS HOUSEHOLD SIZE ANNUAL MONTHLY TWICE PER MONTH EVERY TWO WEEKS WEEKLY 1 $22,311 $1,860 $930 $859 $430 2 $30,044 $2,504 $1,252 $1,156 $578 3 $37,777 $3,149 $1,575 $1,453 $727 4 $45,510 $3,793 $1,897 $1,751 $876 5 $53,243 $4,437 $2,219 $2,048 $1,024 6 $60,976 $5,082 $2,541 $2,346 $1,173 7 $68,709 $5,726 $2,863 $2,643 $1,322 8 $76,442 $6,371 $3,186 $2,941 $1,471 For each additional family member, add: $7,733 $645 $323 $298 $149 FREE MEALS HOUSEHOLD SIZE ANNUAL MONTHLY TWICE PER MONTH EVERY TWO WEEKS WEEKLY 1 $15,678 $1,307 $654 $603 $302 2 $21,112 $1,760 $880 $812 $406 3 $26,546 $2,213 $1,107 $1,021 $511 4 $31,980 $2,665 $1,333 $1,230 $615 5 $37,414 $3,118 $1,559 $1,439 $720 6 $42,848 $3,571 $1,786 $1,648 $824 7 $48,282 $4,024 $2,012 $1,857 $929 8 $53,716 $4,477 $2,239 $2,066 $1,033 For each additional family member, add: $5,434 $453 $227 $209 $105 Please be advised that documentation (photocopy of pay stubs, a food stamp number, or last year s income tax form) is required to substantiate income. If you think you qualify for this program, please call the registration office at 847-327-7003 to request a Basic Fee Waiver application or e-mail kelly.debruler@d128.org.
INSTRUCTIONS FOR APPLYING FOR FREE AND REDUCED-PRICE SCHOOL MEALS APPLICATION Use a separate application for each foster child. List other children together. If you are applying for a FOSTER CHILD, follow these instructions: Part 1: List the child s name, school, and grade. Part 2: 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. If your household gets FOOD STAMPS OR TANF, follow these instructions: Part 1: List each child s name, school, grade, and food stamp or TANF case number. Part 2: Skip this part. Part 3: Skip this part. Part 4: Sign the form. A social security number is not necessary. ALL OTHER 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 all children. Attach another sheet of paper if you need to. Column 2 Last month s income and how often it was received: list the types of income your household got last month and how often you got them. Employment income: list the gross income each person earned last month. It is not the same as take home pay. Gross income is the amount earned before taxes and deductions. It should be listed on your pay stub, or your boss can tell you. Next to the amount, write how often you got it (weekly, every other week, twice a month, or monthly). Other Income: list the total amount each person got last month from all other sources. Include welfare, child support, alimony, pensions, retirement, social security, 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. Report net income for self-owned business, farm, or rental income. Next to the amount, write how often the person got it. 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. Privacy Act Statement: this explains how we will use the information you give us. The 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 children for free or reduced-price meals. The social security number of the adult household member who signs the application is required unless you list food stamp or TANF case numbers for all children you are applying for, OR if you are applying for a foster child. You must check the "I do not have a social security number" box if the adult household member signing the application does not have a social security number. We WILL use your information to see if your children are eligible for free or reduced price meals, to run the program, and to enforce the rules of the program. 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 misuse of program rules. Non-discrimination Statement: this explains what to do if you believe you have been treated unfairly. In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington DC 20250-9410 or call 202-720- 5964 (voice and TDD). USDA is an equal opportunity provider and employer.
LIBERTYVILLE HIGH SCHOOL BASIC FEE WAIVER APPLICATION Please submit the application if you are requesting to have your son s/daughter s BASIC FEE waived for the 2017-2018 School Year. FEES WAIVED include: Basic Fee $250.00 Basic Fee $300.00 (classes of 2018, 2019 & 2020) (class of 2021) Driver Education $245.00 Athletic Fee per Sport $60.00 The following fees are NOT waived: Senior Parking Fee $170.00 Miscellaneous: Gym Lock/Heart Rate Strap $ 5.00 A.P. Exams Student Activity Pass $100.00 Library Fines Lost or Damaged Text Books DATE: STUDENT NAME: STUDENT ID#: GRADE LEVEL: PARENT/GUARDIAN: ADDRESS: PHONE: CITY: ZIP CODE: OFFICE USE ONLY Free or Reduced Lunch Approved Denied Basic Fee $250.00 or 300.00 Approved Denied Driver Education $245.00 Approved Denied If the basic fee waiver is APPROVED, your son s/daughter s account will be credited for BASIC FEES and/or DRIVER EDUCATION ONLY. The remaining fees will be billed at a later date. If the basic fee waiver is DENIED, you will receive an invoice indicating the total amount due. If you have any questions, please call the registration office at 847-327-7003 or e-mail kelly.debruler@d128.org. Parent/Guardian s Signature Date Principal s Signature Date
NOTE: Income verification must be included for every wage-earner in the household. FREE AND REDUCED-PRICE SCHOOL MEALS APPLICATION PLEASE COMPLETE AND RETURN WITH YOUR CHILD S REGISTRATION MATERIALS Part 1. Child in School (USE A SEPARATE APPLICATION FOR EACH CHILD) PRINT STUDENT INFORMATION: (Last, First, MI): School name LHS Grade If you listed a food stamp/tanf case number for EACH child, skip to Part 4. Part 2. Foster Child Food stamp or TANF case # (if any) If this application is for a child who is the legal responsibility of a welfare agency or court, list the amount of the child s personal use monthly income: $. Skip to Part 4. Part 3. Total Household Income From Last Month You must tell us how much and how often 1. NAME (List everyone in household) 2. Last month s income and how often it was received Example: $100/monthly $100/twice a month $100/every other week $100/weekly Earnings from work before deductions PROOF OF IS REQUIRED (attach documentation) Welfare, child support, alimony Pensions, retirement, social security (Example) Jane Smith $200/weekly $150/weekly $100/monthly $ / Other Part 4. Signature and Social Security Number (Adult must sign) 3. Check here if you have no income (Proof will be required) An adult household member must sign the application. If Part 3 is completed, the adult signing the form must also list his or her social security number or mark the I do not have a social security number box. (See Privacy Act Statement on the back of this page.) I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted. Sign here: X Social security number: - - Part 5. Children s Racial and Ethnic Identities (optional) Mark one or more racial/ethnic identities: White, not of Hispanic origin Black, not of Hispanic origin Hispanic I do not have a social security number. You do not have to answer, but it helps us make sure everyone is treated fairly. Asian or Pacific Islander American Indian or Alaskan Native Don t fill out this part. This is for school use only. Monthly Income Conversion: Weekly x 4.33, Every 2 Weeks x 2.15, Twice A Month x 2 Monthly Income: Household size: FS/TANF: Date Withdrawn: Eligibility: Free Reduced Denied Reason: Temporary: Free Reduced Time Period: (expires after days) Determining Official s Signature: Date: