OFFICE OF CHRISTINE LIZARDI FRAZIER KERN COUNTY SUPERINTENDENT OF SCHOOLS Advocates for Children LETTER TO HOUSEHOLDS ABOUT THE NATIONAL SCHOOL LUNCH PROGRAM AND SCHOOL BREAKFAST PROGRAM FOR 2015-2016 SCHOOL YEAR Dear Parent or Guardian: The KERN CO. SUPT. OF SCHOOLS School District/Agency takes part in the National School Lunch and/or School Breakfast Programs. Meals are served every school day. Students may buy lunch for $3.00 and/or breakfast for $1.75. Eligible students may receive meals free or at a reduced price of $.40 for lunch and/or $.30 for breakfast. Students may buy milk for $.50. > If you now receive SNAP, CalFresh, California Work Opportunity and Responsibility to Kids (CalWORKs), Kinship Guardianship Assistance Payments (Kin-GAP), or Food Distribution Program on Indian Reservations (FDPIR) benefits, your child may receive free meals. > If your total household income is the same or less than the amounts on the income scale below, your child may receive meals free or at a reduced price. Household means a group of related or non-related individuals who are living as one economic unit and sharing living expenses. Living expenses include rent, clothes, food, doctor bills, and utility bills. > A foster care child who is the legal responsibility of the welfare agency or ward of the court is eligible to receive free meals regardless of your income. Please mark an "X" in the Foster child box in Section 1 of the meal application and write the name of the child and the specific school the child attends in the areas provided. HOW TO APPLY Complete and sign the attached Application for Free > The names of all adults and other household members, the and Reduced-Price Meals or Free Milk, sign it, and re- amount each person received last month, and the source of turn it to the school as soon as possible. The application income. cannot be approved and may be returned if it contains > The last four digits of the Social Security number of the adult incomplete eligibility information. household member signing the application. If the adult signing does not have one, write "NONE" in the Social Security num- SNAP/CalFresh, CalWORKs, Kin-GAP, and FDPIR ber area or check the box to the right. HOUSEHOLDS - If you now receive any of these benefits for your child(ren), list each child's name, and your SNAP/ An application must be completed, with all household members CalFresh, CalWORKS, Kin-GAP, or FDPIR case number. and incomes listed, for a child who is living with friends or relatives, AN ADULT HOUSEHOLD MEMBER MUST SIGN THE whether or not the child is a ward of the court APPLICATION. An adult household member must sign the application. FOSTER CARE CHILDREN or CHILDREN PLACED IN * A household of one means a foster child, a child in an out-of- OUT-OF-HOME CARE - Complete an application for each home care, or a pupil who is his/her sole support. child who is the legal responsibility of the welfare agency or is a ward of the court. Write an 'X' in the Foster child box in Section 1 of the meal application and INCOME ELIGIBILITY GUIDELINES July 1, 2015 - June 30, 2016 write the name of the child and the specific school the TWICE EVERY child attends in the areas provided. The foster parent HOUSEHOLD PER TWO or agency official must sign the application. SIZE YEAR MONTH MONTH WEEKS WEEK 1* $ 21,775 $ 1,815 $ 908 $ 838 $ 419 ALL OTHER INCOME HOUSEHOLDS (wages, salary, 2 $ 29,471 $ 2,456 $ 1,228 $ 1,134 $ 567 pensions, etc.) - If you do not enter a SNAP/CalFresh, 3 $ 37,167 $ 3,098 $ 1,549 $ 1,430 $ 715 CalWORKs, Kin-GAP, or FDPIR case number for the 4 $ 44,863 $ 3,739 $ 1,870 $ 1,726 $ 863 student(s) listed on the application, you must enter: 5 $ 52,559 $ 4,380 $ 2,190 $ 2,022 $ 1,011 > The names of all school-age children in your 6 $ 60,255 $ 5,022 $ 2,511 $ 2,318 $ 1,159 household and the school(s) they attend. 7 $ 67,951 $ 5,663 $ 2,832 $ 2,614 $ 1,307 > The names of all other children in your house- 8 75,647 hold who do not attend school. For each additional family member, add: $7,696 $642 $321 $296 $148 $ $ 6,304 $ 3,152 $ 2,910 $ 1,455 The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. To file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found at http://www. ascr.usda.gov/complaint_filing_cust.html or at any USDA office, or call (866) 632-9992 to request the form. Or write a letter containing all of the information requested in the form. Send your completed complaint form or letter to: U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or e-mail at 'program.intake@usda.gov'. Individuals who are deaf, hard of hearing, or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.
CURRENT INCOME - The amount of income each household member received last month, before taxes or anything else is taken out, and where it came from, such as earnings, welfare, pensions, and other income. If any amount last month was more or less than ususal, write the usual monthly income or project the annual income. To calculate monthly income: Weekly x 4.33, every two weeks x 2.15, twice a month x 2. INCOME TO REPORT WELFARE PENSIONS EARNINGS CHILD SUPPORT RETIREMENT OTHER FROM WORK ALIMONY SOCIAL SECURITY INCOME Wages, salaries and Public assistance Pensions, supplemental Disability benefits; cash tips, strike benefits, payments, welfare security income, retirement withdrawn from savings; unemployment payments, alimony, and payments, Social Security interest and dividends; compensation, workers' child support payments Income (SSI) (including SSI income from estates, trusts, compensation, net a child receives) and investments; regular income from self-owned contributions from persons business or farm not living in the household; net royalties and annuities; net rental income; any other income FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVA- TIONS (FDPIR) - Households participating in the FDPIR are categorically eligible for free meals or milk. The FDPIR is authorized by Section 4(b) of the Food Stamp Act of 1977. Under this section, eligible households may elect to participate in either the SNAP/CalFresh program or the FDPIR. Since households are afforded the option to participate in either program, FDPIR households have been determined to receive the same categorical benefits as SNAP/CalFresh households. NON-DISCRIMINATION - Children who receive free or reducedpriced meals must be treated in the same manner as those children who pay full price for their meals. FAIR HEARING - If you do not agree with the school's decision regarding your application or the result of verification, you may discuss it with the school. You also have the right to a fair hearing. A fair hearing may be requested by calling or writing the following school official: SOCIAL SECURITY NUMBER - The application must have NAME: MASON HOLLINGSWORTH the the last four digits of the Social Security number of the adult who signs it. If the adult does not have one, write "NONE" in the ADDRESS: 1300 17TH ST. BAKERSFIELD, CA 93301-4533 area for the Social Security number to show that the adult does not have one or check the box to the right. If a SNAP/CalFresh, TELEPHONE: 661-852-5930 CalWORKs, Kin-GAP, or FDPIR case number for the child is listed, or if the application is for a Foster child, the last four digits CONFIDENTIALITY - Family size, household income, and Social of the Social Security number are not required. Security number information will remain confidential and will not be shared for any purpose. Information you provide will determine your APPLYING FOR BENEFITS - You may apply for benefits at any child(ren)'s eligibility to receive free or reduced-price meals. time during the school year. If you are not eligible now but your income goes down, you lose your job, your family size becomes If you have any questions or need assistance in completing the larger, or you become eligible for SNAP/CalFresh, CalWORKS, application, please contact: Kin-GAP, or FDPIR benefits, you may submit an application at at that time. NAME: MASON HOLLINGSWORTH VERIFICATION - School officials may check the information on ADDRESS: 1300 17TH ST. BAKERSFIELD, CA 93301-4533 the application at any time during the year. You may be asked to send information to prove your income, or current eligibility for TELEPHONE: 661-852-5930 SNAP/CalFresh, CalWORKs, Kin-GAP, or FDPIR benefits. Refer to the application for a more detailed explanation. MEALS FOR DISABLED - If you believe your child needs a food substitute or texture modification because of a disability, please contact the school. A child with a disability is entitled to a special meal if the disability prevents the child from eating the regular school meal. A medical statement is required from the child's doctor with specifications. You will be notified by the school when your application has been approved or denied for free or reduced-price meals. Sincerely, WIC PARTICIPANTS - If you currently receive benefits under the Special Supplemental Nutrition Program for Women, Infants, and Children - better known as the WIC Program - your child may be eligible for free or reduced-price meals. You are encouraged to complete an application and return it to the school for processing. ETHNICITY and RACE: Please check appropriate boxes in sections 8 and 9 for students ethnicity and race. Christine Lizardi Frazier Kern County Superintendent of Schools Mason Hollingsworth Food Service Manager
USDA Nondiscrimination Statement 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 available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the informaton requested in the form. To request a copy of the complaint form, call 866-632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Aveenue, SW Washington, D.C. 20250-9410 (2) fax: 202-690-7442; or (3) email: program.intake@usda.gov. This institution is an equal opportunity provider.
Office of Christine Lizardi Frazier Kern County Superintendent of Schools Advocates for Children Application for FREE and REDUCED PRICE meals or FREE MILK for School year 2015-2016 Please complete the application on the reverse, sign the application, and return it to your child's school. For additional instructions, refer to the Letter to Households that is attached to this form. This application cannot be processed without the following information: > The name of the child or children for whom you are applying for Free or Reduced Price meal benefits > The names and income of all other household members > The signature of the child's or children's parent or guardian > The last four digits of the Social Security number of the person signing the application. If the person signing does not have a Social Security number, wirte "NONE" in the area provided for the Social Security number to show the adult does not have one or check the box next to it **RETURN ONLY THE COMPLETED MEAL APPLICATION TO SCHOOL** Print neatly and use BLACK INK only. Use CAPITAL LETTERS only. Any incomplete, unreadable, or incorrect applications will delay meal benefits. All Households: Read This Section 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 National School Lunch Program will not be overtly identified by use of special tokens, special tickets, special serving lines, separate lines, separate entrances, separate dining areas, or by any other means. Privacy Act Statement: National School Lunch Act (Section 9) requires that, unless your child's Supplemental Nutrition Assistance Program (SNAP / Cal Fresh), California Work Opportunity (CalWORKS), Kinship Guardian Assistance Payment (Kin-GAP), or Food Distribution Program on Indian Reservations (FDPIR) case number is provided, you must include the last four digits of the Social Security number of the adult household member signing. Provision of the last four digits of a Social Security number is not mandatory, but the application cannot be approved if the last four digits of the Social Security number are not provided, or the box to the right is not marked indicating that the signer does not have such a number, or the word NONE is written in the Social Security number area. The last four digits of the Social Security number may be used to identify household member in carrying out efforts to verify correct information provided on the application. These verification efforts may be carried out through program reviews, audits, investigations and may include contacting employers to determine income, contacting the State's Employment Development Department or local welfare offices to determine the amount of benefits received, and checking documentation produced by household members to prove the amount of income received. Reporting incorrect information may result in loss or reduction of the household's program benefits, or in administrative claims and/or legal actions against household members.
Kern County Superintendent of Schools Staff Date Approved App. # 2015-2016 Use Free Reduced Paid Hsehold # Income $ National School Lunch Program Only Meal Benefit Income Eligibility Form **Please refer to instructions on back. Use BLACK INK. Print neatly within the boxes. Complete ONE application per student and household.** 1 Homeless, Migrant, Runaway - If the child you Mark an "X" here if application is for a child who is the legal responsibility of Student I.D. # are applying for is homeless (H), migrant (M), or a H M R a welfare agency or court. If you place an X in the box, please skip the runaway (R), circle the appropriate box. Income Information Section '4'. Go directly to Section 6 and sign application. 2 Using BLACK INK, Student's First Name MI Student's Last Name Grade Food Service Staff Use Only - Notes: Print Clearly and complete the following information: School Name Teacher Name Student's Monthly Income (if any) (i.e. Salary/Wages, Child SSI Monthly PERSONAL USE income) $ 3 If you are currently receiving any of the following benefits - If you list a Case #, please skip the next section, Section '4'. CalFresh, SNAP, CalWORKS, Kin-GAP, or FDPIR, list the Case #: Go directly to Section 6, sign and date the application. 4 ALL OTHER HOUSEHOLD MEMBERS (DO NOT INCLUDE THE ENROLLED STUDENT LISTED ABOVE) - Complete this section if you did not complete Parts 1 or 3. Report all current monthly income received last month before taxes and deductions. *To determine monthly income: Multiply Weekly Income x 4.33, or every 2 Week Income x 2.15, or Twice a Month Income x 2. 5 Print Clearly If NO Income, Gross Earnings from work Welfare payments, Pension, Retirement, Other Income, including First and Last Names of ALL put an X in before Deductions Child Support, Alimony Social Security Temporary Income other household members. box below MONTHLY* MONTHLY* MONTHLY* MONTHLY* Mailing Address City Zip Code State Area Code Phone Number Signature: The household adult who completed this application must sign and date below (6). Only the last four digits of their Social Security number are required (7), but the last four digits are NOT required on CalFresh, SNAP, CalWORKS, Kin-GAP, FDPIR or Foster child applications. If you DO NOT have a Social Security number, check the box provided for that OR write the word NONE in the Social Security Number box. 6 SIGNATURE of ADULT HOUSEHOLD MEMBER REQUIRED Date Signed 7 Adult Household Member Social Security Number Check box here if you DO NOT have 2 0 X X X X X a SOC. SEC. # Month Day Year Last four (4) digits only PRINTED NAME of Adult Household Member Signing Application 8 Race American Indian Black or African Native Hawaiian or 9 Of Hispanic or NOT of Hispanic Identity. Mark or Alaska Native Asian American Other Pacific Islander White Ethinc Identity Latino Origin one or more Mark one Certification: I certify that all the information provided above is true and correct and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, that school officials may verify the information on the application and that deliberate misrepretentation of the information may subject me to prosecution under applicable State and Federal Laws. Calif. Ed. 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 Nat'l School Lunch Program will not be overtly identified by use of special tokens, special entrances, special serving lines, separate tickets, separate dining areas, or by any other means. Food Service Staff Use Only or Latino Origin