Electra Star-News (Electra, Tex.), Vol. 88, No. 49, Ed. 1 Thursday, July 27, 1995 Page: 6 of 22
twenty two pages : ill. ; page 21 x 13 in.View a full description of this newspaper.
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*
School Breakfast Program
1995-96 INCOME ELIGIBILITY GUIDELINES
FAMILY
SIZE
FREE
FREE
FREE
$ 13,820
$ 187
1,941
-fy-r' 2,336 !'
i>- -
> -
1,919
2,731
443
2,196
fS
fc;’ -
3,125
7
2,474
571
.2,751
i
9
3,029
4,310
10
4705
56,444
3,307
11
5,100
42,991
61,180
3,585
827
1,180
?
3,863
6,495
891 ' '
46,319
65,916
1,272
+ $ 278
+ $ 395
+ $64
+ $ 92
+ ■>2
APPLICATION FOR FREE
AND
£•
ft
AFDC NUMBER
FOOD STAMP NUMBER
OR
Don Windham, Superin-
tendent
NAMES OF HOUSEHOLD MEMBERS
Job 2
Job 1
APPLICATION
4
X
X
instructions
American Indian/Alaskan Native
White, not Hispanic Black, not Hispanic Hispanic Asian/Pacific Islander
. f
TOTAL HOUSEHOLD SIZE
AFDC
FOOD STAMP
MONTHLY INCOME
ELIGIBILITY DETERMINATION-. APPROVED FREE APPROVED REDUCED-PRICE DENIED TEMPORARY UNTIL UNTIL UNTIL
INCOMPLETE APPLICATION
OTHER.
REASON FOR DENIAL: INCOME TOO HIGH
DATE WITHDRAWN
CHANGE IN STATUS
DATE
REASON
R V I\» 'FT1IMI IIIFNIIIV • ••mpM* <h* r» MMhnfc Mntflt* •<
DATE.
SIGNATURE OF DETERMINING OFFICIAL
t*i
8
1
il
DATE:
SIGNATURE OF VERIFYING OFFICIAL:.
DATE NOTICE OF CHANGE SENT TO PARENT/GUARDIAN:
S.
S
s
$
$.
s'
s
BE DISCRIMINATED
AGAINST BECAUSE OF
RACE, SEX, COLOR, NA-
1994-95 Breakfast
& Lunch Prices
Student Lunch, Reg.
Student Lunch, Red.
Teacher Lunch
Visitor Lunch
Signature of Adult Household Member
HOME TELEPHONE NO. WORK TELEPHONE NO.
Gross MONTHLY Earnings MONTHLY
(Before Deductions)
Social Security Number*
PRINTED NAME
Welfare Payments,
Child Support,
Alimony
S
s
s
5
s
s_________
$ _________
■y .
INCOME TORFPOHT
Monthly
I !52
I 547
1 941
2 336
2.731
3 125
3.520
3.915
We-klv
266
357
448
53»
6’1
722
81’
004
I
;!?■-
Any Other
MONTHLY
DIATELY TO THE SEC-
RETARY OF AGRICUL-
TURE, WASHINGTON, D.C.
20250.
We will let you know when
I
i
f
National School Lunch Program
igii
k
4
REDUCED PRICE MEALS
A -
In ligurr Mi'iHlih In, ••me
PARC* MGNAIURF AND MX I A!
Ill AH applirst*’i
l?l lheappht
number *iH«- n»»nr m
tir Al Ul • munh-i rath
FART <
tn iht* .jnrtthm hr*
feltlv
12
For each additional family member add:
+ $ 3,328 + $ 4,736
$ 1,152
r. 1/547
3,520
" * 3,915’
$ 9,711
$ 266
> ;251<y><- *<■ +
448
16,367
•• mm ►
In<*i <—*•
29,679
I
&
i
p
I
lit'
T;-
£
42,236
\^46;972 "
36,335
39,663 "
1
To apply for free and reduced-price meals, complete this application, sign your name and return the application to the school. Call the
school if you need help. #
IT TO THE SCHOOL. WE
CANNOT APPROVE AN
APPLICATION THAT IS
NOT COMPLETE. .
INCOME CHART
Annual
13.820
18.556.
23.292.
28.028
32.764
37 500
42.236
46.972
3 FOSTER CHIT .Dr List the child’s monthly personal use income. Write “O” if the child has no personal use income. $ .
4 HOUSEHOLD MEMBERS AND MONTHLY INCOME: If you gave a food stamp or AFDC case number for the child, skip to PART 5.
1 Print STUDENT INFORMATION.
NAME GRADE
STREET/APT. NO. CITY/STATE/ZIP_ _____________DATE_
6 RACE: Please check the racial or ethnic identity of your child(ren). You are not required to answer this question.
DATE VERIFICATION NOTICE SENT: RESPONSE DUE FROM HOUSEHOLD _SECOND NOTICE SENT
VERIFICATION RESULT NO CHANGE FREE TO REDUCED-PRICE FREE TO PAID REDUCED TO FREE REDUCED-PRICE TO PAID
REASON FOR ELtGIBH-TTY CHANGE: INCOME HOUSEHOLD SIZE REFUSED TO COOPERATE O1HER_ CHANGE IN FOOD STAMP/AFDC.
Student Breakfast, Reg. .40
Student Breakfast, Red. .30
Teacher Breakfast .55
23,292
.•7W28,028^^
t!
I
4
_5______
..z<; -
<■?+ V
$ 810
1^^087''-
1
3
I
ft
I
699
•• - 7e3
•PRIVACY ACT STATEMENT: SECTION 9 OF THE NATIONAL SCHOOL LUNCH ACT REQUIRES THAT. UNLESS YOUR CHILD’S FOOD STAMP OR AFDC CASE NUMBER IS PROVIDED. YOU MUST INCLUDE THE
SOClALSECUWTYNUMBEROFTHEADULTHOUSEHOLDMEMBERSIGNINGTHEAmJCATIONORINDICATETHATTHEHOUSEHOLDMEMBERDOESNOTHAVEASOCIALSECURITYNUMBER. PROVISION
OF A SOCIAL SECURITY NUMBER, IS NOT MANDATORY. BUT IF A SOCIAL SECURITY NUMBER IS NOT GIVEN OR AN INDICATION IS NOT MADE THAT THE SIGNER DOES NOT HAVE SUCH A NUMBER, THE
APPLICATION CANNOT BE AFP8.OVE0. THE SOCIAL SECURITY NUMBER MAY BE USED TO IDENTIFY THE HOUSEHOLD MEMBER IN CARRYING OCT EFFORTS TO VERIFY T HE CORRECTNESS OF
INFORMATION STATED ON THE APPLICATION. THESE VERIFICATION EFFORTS MAYBE CARRIED OUT THROUGH PROGRAM REVIEWS, AUDITS. AND INVESTIGATIONS AND MAY INCLUDE CONTACTING
EMPLOYERS TO DETERMINE INCOME CONTACTING A POOD STAMP OR WELFARE OFFICE TO DETERMINE CURRENT CERTIFICATION FOR RECEIPT OF POOD STAMPS OR AFDC BENEFITS, CONTACTING
THE STATE EMPLOYMENT SECURITY OFFICE TO DETERMINE THE AMOUNT OF BENEFITS RECEIVED AND CHECKING THE DOCUMENTATION P RODUCED BY H OUSEHOLD MEMBERS TO PROVE THE
AMOUNT OF INCOME RECEIVED. THESE EFFORTS MAY RESULT TN A LOSS OR REDUCTION OF BENEFITS, ADMINISTRATIVE CLAIMS OR LEGAL ACTIONS IF INCORRECT INFORMATION IS REPORTED.
| FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE |
=a = =S=2=3CS=SS==It==S=Z = S====S=2 = =i=3==I= = S3a3C= = = SX = CXXS=3=3=S = =3=l=3«I==Sr3S:Z==I = =S = =S=2=S=3 = = = = = =: = =S=SXSt=:S3=S=:C= = = «=S = = = =a= = a==«=a=2
MONTHLY INCOME CONVERSION: WEEKLY X 4.33 EVERY 2 WEEKS X 2.15 T^ICE A MONTH X 2
have i
a food
32,764
*^•37,500^"'
315
» i
8
813
‘ . > '904
REDUCED
PRICE
The Electra Independent
School District serves meals
each school day. Children
may buy lunch for 1.25 and
breakfast for .40. Children
may also get meals free or at
a reduced price.
If you now get food stamps
or AFDC for your children,
your children can get free
meals. If your total house-
hold income is the same or
less than the amounts on the
Income Chart below, your
children can get free meals or
reduced price meals. A fos-
ter child may get free or re-
duced price meals regardless
of your income. The reduced
price is .40 for lunch and .30
for breakfast.
TO GET FREE OR RE-
DUCED PRICE MEALS FOR Confidentiality: School of-
-- ficials use the information on
the application only to decide
i
li
£
You may also ask for a fair
hearing. You may do this by
calling or writing:
Don Windham, 817-
495-3683
621 N. Waggoner, Elec-
tra, Texas 76360
Reporting Changes: If your
children get free or reduced
price meals because of your
income, you must tell the
school if your household size
decreases or your income in-
creases by more than $50 per
month of $600 per year. If
your children get meals be-
cause you get food stamps
or AFDC, you must tell the
school when you are not get-
ting AFDC or food stamps
for them. You may then fill
out another application giv-$
ing income information.
63Blf'
MONTHLY
Payments from
Pensions, Retiremeit, Income
Social Security
S.
$.
S
$'
S.
S.
s'
2 List the child’s FOOD STAMP or AFDC case number, if any.
NAME OF SCHOOL
__________________________________________________________s____________s
___________________ *_____________ s_______________s
__________________________________________________________s____________s
_____________________________^_s______s
_______________________________________________________________________s_______________s'
____________________________s______s
__________________________________________________________s____________s
5 SIGNATURE AND SOCIAL SECURITY NUMBER: I certify that all of the above is true and correct and that all income is reported. I
understand that this infonnaiion is bong given for the receipt of federal funds; that school officials may verify the information on the application; and that
deliberate misrepresentation of the information may subject me to prosecution under Applicable state and federal laws.
631
%-■ 722j< t ,
< .a .. 507 ’ ...
Electra Star-News, Thursday, July 27, 1995 Page Eight
Electra Independent Sdfidcfl Dii?frict
NATIONAL SCHOOL LUNCH
AND CHILD NUTRITION PROGRAMS
adult household member. If
you are applying for a foster
haye’th^chHd’slamerthe SJ^’.^OCHILDWILL
child’s ‘personal use’ income,
and an adult signature. If
you do not list a food stamp
or AFDC case number for Q?
all children you are applying
for, then the application must
have the children’s names,
•J
1.25
.40
1.60
2.00
23,023
Zo(30 I t
Househnld Size
1
2
3
4
5
6
7
8
For each
add’l member
add. +4.736.
51,708
1,364
■1^^1,642
+ 395
How To Apply
YOUR CHILDREN, YOU
MUST COMPLETE AN AP-
PLICATION AND RETURN if your children should get
free or re(juce(] price meals.
Reapplication: You may
apply for meals anytime dur-
ing the school year. If you
are not eligible now, but
have a change in status, like
a decrease in household
come, an increase in house-
hold income, an increase in
household size, become un-
employed, or get food stamps
of AFDC for your children,
you may then complete an ap-
plication.
. * . Handicapped: Meal substi-
If you now get food stamps tutions at no additional cost
or AFDC for the children you for children who meet the
are apply for, the application definition of ‘handicapped’
must have the children’s will be served, provided physi-
names, a food stamp of cian has submitted a statigf
AFDC case number for each ment attesting to this fact
child, and the signature of an and prescribing a substitute.
IN THE OPERATION OF
THE CHILD FEEDING PRO
help f_ ..
l-ARTI SIVnFNTINHIRMAIION- Al t IIOPSFHOLOS COMPLETE THIS PART
(I) Piirt lhe Mmrt «4 th. ihihti.n ue >TTb*nt h»
121 1 1,1 thHr ztmlf mt «h,..l ____________
PARTI ItOIISFItOIIISCFniNCKHIIIirAMrSORAFnC: COMPLETE THIS PART and PART S
(It 11« a rmtfflt 6,xl .tamp <» Al tK' cA.« mimhet Im exh child
iNS.fPtheaiTlpatt.minPARtl An adullhmt<rt«4d memhet mu.Bljn SKIJtARl* Dnla|llllnameiolh<ntte1mld
memhei'm nnmne >1 ymt hu a l,.,l .lamp m AFIX rue tximhct for exh cMId
PARTI IltHKFIHH IIS Willi A FOSITR LIHIJ): COMPLETE THIS PART and PART S . A Inalrf child l< the lejal
Irr.mlbll7.td^»Hlxeh»ern> (1W- W|ht -o- |,|hert|tdd,«n not ,et ‘pettonal»«’ Income
SKIP PARI 4 <”•* I’M •’thri «h»l4»«+n ht«meh»»1J member* nr Income
t?l A hntet parent m ••rhet olhujl rer«e<en«m|t she child rrwl tign the appl'ritfem tn PART 5
-Pctonal me mt..me •« tat mm.., I., dm ..Hate ..like (demlPed h, <atep»| l.« the .htld < pettonal u.e wth at Im
•thehme > hoot t— ami alhtnamm 1ml .Mallrthrt trnme,the.hlld Jett, .nth a. mime. tom.httlhet lamil, and tmme, (torn
Ihr . tidal \ hill 1IH»r ••» ••‘j’tlla* fMIt ‘"W !••«•* ___________________ ___
min r notisnioi < <>mpi ete this part «mi part s
Ath* Um •» ''-tv’nr m wrm htwwhuhl whether they get income «•» fmlwle ynurtelf the children you
ate wrl,.nt l... all.elm. 't-'"' pandpaeenl. ml whet related and untelaMl rttTle in ,™. hm>.eh.ld Hte
inarthrr rip'r "I fire'H ¥«•» or-nl n>"’e hp*.r . , . . .
UtH'the amtmirtt.l irH«me h hornrhoM member pH IlHfflSjnth helrne me* ♦« inyihlng et*e »« liken mH JCjJ
where H . line h-m *«■ b a* earning *rlfarr prmy.m and .rther Income »>ny imrmiH l«l month was morenr 1e«« ihan o’uil
mite that net-«-n « ntriat monthly imoine
11, An adult hrmwlmld member mmi «»”• Vplteathm and give hit/hrt tncial *rv«»«v number in TART *
Wreklv * 4 11 Pvery 2 Week* A 7 IS Twne a Mimih t 2____________________
sfi t'Rin numbfR: aii iintisnioi ns m'mpi ftf this part
m« mn*t have di* *i£iMime of an adult hou«choltl member
mini ha’ e the -Kid ui riv number -I the adult who cigm It the arh.ti eb^ mH have a uk ul m m9 ,
wtnrihlng d*e h. chow th al the adult doe* not have a 4ocW w it y numbet It ymi Hued a t.-d
.hdd m H wiu me applying lor a foUer child » WiirHv numhgr I* no* needed
---- -----— -( ^.aaa with V»«l nft T»Cj^i,ed
trdmrd pine meala We nerd this hdiwmaiinn m make *u»e that everyone h
----- ----—
£
>».rn» I itataaVT
Aaoii* -ertWmWre*
HANDICAP. IF YOU BE-
LIEVE YOU HAVE BEEN
DISCRIMINATED
the names of all household IM.ME-j|
members, the amount of
income each person got last
month and where it came
from, the signature of an
adult household member and
the adult’s social security your application is approved
number or the word ‘none’ or denied,
if the adult does not have a Sincerely,
social security number.
Verification: Your eligibil-
ity may be checked at any
time during the school year.
School officials may ask you
to send papers showing that
your children should get free
or reduced price meals.
Fair Hearing: You may
talk to school officials if you
do not agree with the school’s
decision on your application
or the results of verification.
996
z z
: ’1,038
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Electra Star-News (Electra, Tex.), Vol. 88, No. 49, Ed. 1 Thursday, July 27, 1995, newspaper, July 27, 1995; Electra, Texas. (https://texashistory.unt.edu/ark:/67531/metapth1233735/m1/6/: accessed July 17, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting Electra Public Library.