Manteca Unified School District
LETTER TO HOUSEHOLDS ABOUT the NATIONAL SCHOOL LUNCH PROGRAM
and SCHOOL BREAKFAST PROGRAM for 2009-2010
Dear Parent or Guardian:
The Manteca Unified School District School District takes part in the National School Lunch and/or School Breakfast
Programs. Meals are served every school day at participating schools. Elementary students may buy lunch for $1.50 and/or
breakfast for $.75. Secondary students may buy lunch for $1.75 and/or breakfast for $1.00. Eligible students may receive
meals free or at a reduced price of 40
¢
for lunch and/or 25
¢
for breakfast.
•
This district/agency participates in
Direct Certification:
In a school participating in a meal program, your child is
automatically certified to receive free meals, if your household currently receives Food Stamp (FS), or if your child receives
California Work Opportunity and Responsibility to Kids (CalWORKs), Kinship Guardianship Assistance Payments (KinGAP), or
Food Distribution Program on Indian Reservations (FDPIR) benefits. (See “HOW TO APPLY – FOOD STAMP. . . BENEFITS” below.)
•
A foster care child who is the legal responsibility of the welfare agency or ward of the court may be eligible to receive meals
free or at a reduced price regardless of your income. Foster children must have a separate application from other children in
your household, and their eligibility is based on their “Personal Use Income.” (See “HOW TO APPLY – FOSTER CARE. . .” below.)
•
If you do not receive benefits automatically qualifying your child for free meals, you may apply for free/reduced-price meals for
your child(ren). 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.
(See “HOW TO APPLY – INCOME HOUSEHOLDS” below.)
HOW TO APPLY
FOOD STAMP, CalWORKS, KINGAP, and FDPIR BENEFITS:
If your household receives Food Stamps (FS), or if your
child receives CalWORKs, KinGAP, or FDPIR benefits, you
DO NOT COMPLETE A MEAL APPLICATION
. School
officials will notify you of your child(ren)’s eligibility for free
meals
. If you are not contacted within 30 days of the
start of school, but think your child(ren) is/are eligible
for free meals, please contact the school to complete an
application.
FOSTER CARE CHILDREN or CHILDREN PLACED IN
OUT-OF-HOME CARE—Complete a separate application
for each child who is the legal responsibility of the
welfare agency or is a ward of the court.
Write the name
of the child and the specific school the child attends. If the
child receives personal-use income, list the amount of
income. Personal-use income is (a) money given by the
welfare office identified by category for the child's personal
use, such as clothing, school fees, and allowances; and (b)
all other money the child receives, such as money from
family and earnings from full-time or regular part-time
employment.
The foster parent or agency official must
sign the application.
INCOME HOUSEHOLDS (wages, salary, pensions, etc.)
To apply for free or reduced-price meals for your
child(ren), complete the attached Application for Free
and Reduced Price Meals or Free Milk
, sign it, and return it
to the school as soon as possible. The application cannot be
approved unless it contains complete eligibility information.
If you
do not
enter a FS, CalWORKs, KinGAP, or FDPIR
case number for
each
student listed on the application, you
must enter the following (go to next column):
•
The names of
all
school-age children in your household
and the school(s) they attend.
•
The names of
all
other children in your household who
do not attend school.
•
The names of
all
adults and other household members,
the amount each person received last month, and the
source of income.
•
The
Social Security
number of the adult household
member who signs the application or indicate "none" if
the adult does not have a social security number.
An application must be completed, with all household
members and income listed, for a child who is living with
relatives or friends, whether or not the child is a ward of the
court.
An adult household member must sign the application.
*
A household of one means a foster child, a child in out-of-
home care, or a pupil who is his/her sole support.
INCOME ELIGIBILITY GUIDELINES
July 1, 2009 - June 30, 2010
HouSizsee hold
Year
Month
TWICMPonter
h
E
2
EVERWEEKY
S
Week
1*
$20,036
$ 1,670
$
835
$
771
$ 386
2
26,955
2,247
1,124
1,037
519
3
33,874
2,823
1,412
1,303
652
4
40,793
3,400
1,700
1,569
785
5
47,712
3,976
1,988
1,836
918
6
54,631
4,553
2,277
2,102
1,051
7
61,550
5,130
2,565
2,368
1,184
8
68,469
5,706
2,853
2,634
1,317
For each additional family member, add
:
$ 6,919 $ 577
$ 289
$ 267
$ 134
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 USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW,
Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.
Material prepared according to the California Department of Education, Child Nutrition and Food Distribution Division
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 usual, 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
EARNINGS
FROM
WORK
Wages, salaries and
tips, strike benefits,
unemployment
compensation, workers'
compensation, net income
from self-owned business
or farm.
WELFARE
CHILD SUPPORT
ALIMONY
Public assistance
payments, welfare
payments, alimony, and
child support payments.
PENSIONS
RETIREMENT
SOCIAL SECURITY
Pensions, supplemental
security income, retirement
payments, Social Security
Income (SSI) (including SSI
a child receives).
OTHER
INCOME
Disability benefits; cash
withdrawn from savings; interest
and dividends; income from
estates, trusts, and investments;
regular contributions from
persons not living in the
household; net royalties and
annuities; net rental income; any
other income.
FOOD DISTRIBUTION PROGRAM ON INDIAN
RESERVATIONS (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 Food Stamp 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
Food Stamp households.
SOCIAL SECURITY NUMBER
—The application must
have the social security number of the adult who signs it. If
the adult does not have a social security number, write
"none" or something else to show that the adult does not
have a social security number.
If a Food Stamp,
CalWORKs, KinGAP, or FDPIR case number for the child
is listed, or if the application is for a foster child, a social
security number is not required.
APPLYING FOR BENEFITS
—You may apply for benefits
at any time during the school year. If you are not eligible
now but your income goes down, you lose your job, your
family size becomes larger, or you become eligible for
Food Stamp, CalWORKs, KinGAP, or FDPIR benefits, you
may submit an application at that time.
VERIFICATION
—School officials may check the
information on the application at any time during the school
year. You may be asked to send information to prove your
income, or current eligibility for Food Stamp, CalWORKs,
KinGAP, or FDPIR benefits. Refer to the application for
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 at no extra charge if
the disability prevents the child from eating the regular
school meal.
WIC PARTICIPANTS
—If you currently receive benefits
under the Special Supplemental Nutrition Program for
Woman, 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.
NONDISCRIMINATION
—Children who receive free or
reduced priced 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 decision
regarding your application or the result of verification, you
may discuss it with Nutrition Services. You also have the
right to a fair hearing. A fair hearing may be requested by
calling or writing the following school official:
Director of Operations
2271 West Louise Avenue, Manteca, CA 95337
P.O. Box 32, Manteca, CA 95336
209-825-3200, ext. 50733
CONFIDENTIALITY
—Family size, household income, and
social security number information will remain confidential
and will not be shared for any purpose. Information you
provide will determine your child(ren)s eligibility to receive
free or reduced-price meals.
If you have any questions or need assistance in completing
the application, please contact the Nutrition Services
Department at (209)825-3200, ext. 50733.
You will be notified by Nutrition Services when your
application has been approved or denied for free or
reduced-price meals.
Sincerely,
Manteca Unified School District
Steve Trantham
Director of Operations
APPLICATION FOR FREE AND REDUCED-PRICE MEALS
FOR SCHOOL YEAR 2009-2010
SECTION A. STUDENT INFORMATION:
Complete this section by providing information for
all
of the
children
in your household.
STUDENT
/ CHILD INFORMATION
FOOD STAMP,
CALWORKS, KIN-GAP,
OR
FDPIR BENEFITS
FOSTER CHILD
(MUST HAVE SEPARATE
APPLICATION)
FOR SCHOOL
USE ONLY
LAST NAME
FIRST NAME
CURRENT SCHOOL
(
WRITE "N/A" IF NOT
IN SCHOOL)
WRITE
“
YES”
OR
“NO”
IF “YES,” WRITE
CASE NUMBER
BELOW
WRITE
“
YES”
OR
“NO”
IF “YES,” ENTER
CHILD’S MONTHLY
“
PERSONAL-USE”
INCOME
STUDENT ID
SECTION B. HOUSEHOLD MEMBERS AND MONTHLY INCOME:
If in Section A you entered a Food Stamp, CalWORKs,
Kin-GAP, or FDPIR case number for
each
child, or if this application is for a foster child and you entered monthly personal-use
income, go to signature block in Section C.
Foster Child:
In some cases foster children are eligible for free or reduced-price
meals or free milk regardless of the household's income. If you have foster children living with you and you wish to apply for meal
or milk benefits for them, please contact your school's food administrator.
List all adult household members, regardless of whether or not they have income
. Indicate the amount and source of
monthly income each household member received last month. If any amount last month was more or less than usual, enter the
usual monthly income. Also, enter any income received by or for a child from full-time or regular part-time employment, Social
Security Income, or Adoption Assistance.
FULL NAME
GROSS MONTHLY
EARNINGS FROM WORK
(
BEFORE DEDUCTIONS)
INCLUDE ALL JOBS
PENSION,
RETIREMENT,
SOCIAL SECURITY
WELFARE BENEFITS,
CHILD SUPPORT,
ALIMONY PAYMENTS
ANY
OTHER
MONTHLY
INCOME
FOR SCHOOL
USE ONLY:
TOTAL MONTHLY
INCOME
SECTION C.
I certify that all of the above information 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
at any time, and that deliberate misrepresentation of the information may subject me to prosecution under applicable State and
federal laws.
SIGNATURE OF ADULT HOUSEHOLD MEMBER COMPLETING THIS FORM
TELEPHONE NUMBER
(
)
DATE
PRINTED NAME OF ADULT HOUSEHOLD MEMBER WHO COMPLETED THIS
FORM
SOCIAL SECURITY NUMBER (WRITE “NONE” IF N/A)
MAILING ADDRESS
CITY
ZIP CODE
TOTAL ADULTS AND CHILDREN IN HOUSEHOLD
SECTION D. CHILDREN’S RACIAL AND ETHNIC IDENTITIES (Optional):
1. Mark one or more racial identities:
American Indian or
Asian
Black or
Native Hawaiian or
White
Alaska Native
African American
Other Pacific Islander
2. Mark one ethnic identity:
Of Hispanic or Latino origin
Not of Hispanic or Latino origin
FOR SCHOOL USE ONLY - ELIGIBILITY DETERMINATION
Free
Reduced
Denied
Categorically
Free
with Food Stamp, CalWORKs, Kin-GAP, or FDPIR Benefits
Zero Income, Temporary Free Until (Up to 45 calendar days from date of this determination):
Direct Certified as: H M R
EP
Year Round Track:
Household Size:
Household Income:
Determining Official:
Date:
2
nd
Review – Official:
Date:
Verification Official:
Date:
Follow up:
LUNCHBOX # ____________
□
Check if NEW Student
in Manteca Unified
Complete
ONLY ONE
application per household.