School Year 2017 - 2018

Instructions: If you have more than six (6) students or more than eight (8) people in your household (including students),
you must fill out a paper application. Paper applications are available at the front office of your child's school as well as the
Healthy Meals Application Center.

 

Food and Nutrition Services

2700 Judge Fran Jamieson Way

Viera, FL 32940

(321)633-1000 ext 642

 

When filling out this application click on the Instructions Button in each section for detailed instructions. If you still have
questions, please contact the Healthy Meals Express Application Center by phone.

 

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

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

Previous App
or Status

PART 1. Homeless, Migrant and Runaway Children

Click below
to populate
student ID

Please note a valid case number contains only 10 digits and begins with 10, 11, 12, 13, 14 or 15EX. 1200305555

PART 2. SNAP/TANF (Formerly Food Stamps)

Student ID

Date of Birth

PART 3. Student Information (Parents must fill out a paper application if there are more than six(6) students in the household)

MI

School/Campus

First Name

Last Name

Grade

*******

*******

*******

*******

*******

*******

An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list
the last four (4) digits of his or her Social Security Number or mark the “I do not have a Social Security Number” box.

Guardian SSN (last 4 digits)

PART 4. Guardian Information


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

If there are more than eight(8) people in the household you must use a paper application.

Total Number of Household Members

List everyone in the
household including
students listed above.

List your income and how often it is received.

Check
if no
Income

(W)= Weekly(B)= Biweekly(T)= Twice a Month(M)= Monthly(Y)Yearly

Earning from Work
before deductions

Welfare, Child
Support, Alimony

Social Security,
Pension, Retirement

Other Income.

First Name

Last Name

Race / Ethnic Identity (Optional)

Mark one or more racial identities:

Florida KidCare - Many children who qualify for the free and reduced price school meal program also qualify for low cost or
free health insurance from KidCare. If interested, you may contact Florida KidCare at 1-888-540-5437, or by visiting their
website at:

http://www.floridakidcare.org

CONFIDENTIALITY: School officials use the information on the application to decide if your child should receive free or
reduced price meals. We may inform officials connected with other child nutrition, education, health, and health insurance
programs of the information on your form to determine benefits for those programs or for funding and/or evaluation purposes.

I DO NOT WANTthis application used in determining other benefits for my child.

PART 6. Digital Signature and compliance affirmations.

YOU MUST ACCEPT BOTH STATEMENTS FOR YOUR APPLICATION TO BE PROCESSED

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.

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

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 information 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 mail:

        U.S. Department of Agriculture

        Office of the Assistant Secretary for Civil Rights

        1400 Independence Avenue, SW

        Washington, D.C. 20250-9410

fax: (202) 690-7442; or email:program.intake@usda.gov.

 

This institution is an equal opportunity provider.

 

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