APPLICATION FOR FREE & REDUCED-PRICE MEALS

School Year 2023 - 2024

Application Identification Number

Food and Nutrition Services:

904-547-8931

PART 1. Homeless, Migrant and Runaway Children

If you are applying for a child that is homeless, migrant or
runaway please check the appropriate box.

Homeless

Migrant

Runaway

None

PART 2. SNAP/TANF (Formerly Food Stamps)

If you have a SNAP or TANF case number please enter the number here:

Please note a valid case number contains only 10 digits:

EX. 1200305555

PART 3. Student Information (Use additional applications for more than six (6) students)

Date of Birth

First Name

Last Name

Student ID

School/Campus

Grade

Is the student listed above a Foster Child?

Yes

No

Is the student listed above a Foster Child?

Yes

No

Is the student listed above a Foster Child?

Yes

No

Is the student listed above a Foster Child?

Yes

No

Is the student listed above a Foster Child?

Yes

No

Is the student listed above a Foster Child?

Yes

No

PART 4. Signature and Social Security Number (Adult MUST sign)

An adult household member must sign the application. If Part 4 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.

I do not
have a SSN

Guardian First Name

Guardian Last Name

Guardian SSN (last 4 digits)

Address

Apt Number

Home Phone

City

State

Zip

Work Phone

EMail

PART 5. Total Household Income from last month (You must list ALL INCOME to qualify)

Check
if no
Income

How many dollars did each person in the household make last month?

(W)= Weekly

(E)= Every Two Weeks

(T)= Twice a Month

(M)= Monthly

(Y) Yearly

List everyone in the household
including students listed above.

Earning from Work
before deductions

Welfare, Child
Support, Alimony

Social Security,
Pension, Retirement

Other Income

First Name

Last Name

Total Number of
Household Members

Income

Frequency

Race / Ethnic Identity (Optional)

Mark one ethnic identity:

Hispanic or Latino

Non Hispanic or Latino

Mark one or more racial identities:

American Indian or Alaska Native

Native Hawaiian or Pacific Islander

Asian

White

Black or African American

Other

PART 6. Digital Signature and compliance affirmations.

YOU MUST ACCEPT BOTH STATEMENTS FOR YOUR APPLICATION TO BE PROCESSED

Agree

Decline

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.

Agree

Decline

By my electronic submission of this application I verify my understanding/agreement with the above
statement and all USDA and the State of Florida Guidlines regarding the Free and Reduced School Lunch
Program.

Click here for Guardian Signature

Notes

Reviewed By (School Use Only)

Application ID