School Year 2020 - 2021

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
or online at


Food and Nutrition Services

2700 Judge Fran Jamieson Way

Viera, FL 32940

(321)633-1000 ext 11642


When filling out this application click on the Instructions Button in each section for detailed instructions. If you still
have questions, please contact the Office of Food & Nutrition Services at 321-633-1000 x11642.


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:

PART 1. Homeless, Migrant and Runaway Children

Previous App
or Status

Click below
to populate
student ID

EX. 1200305555

PART 2. SNAP/TANF (Formerly Food Stamps)

Please note a valid case number contains only 10 digits and begins with 10, 11, 12, 13, 14, 15 or 16.

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

Student ID

Date of Birth



First Name

Last Name








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.

PART 4. Guardian Information

Guardian SSN (last 4 digits)

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. List '0' if no income.

Any income field left blank will indicate no income for the individual.

if no

(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:

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.


this application used in determining other benefits for my child.

PART 6. Digital Signature and compliance affirmations.


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

The Richard B.Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not,
we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household
member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list
a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on
Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the
application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price
meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education,
health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law
enforcement officials to help them look into violations of program rules.

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://, 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

        U.S. Department of Agriculture This institution is an equal opportunity provider.

Office of the Assistant Secretary for Civil Rights

        1400 Independence Avenue, SW

        Washington, D.C. 20250-9410

fax: (202) 690-7442; or email: