Notefeed - Pointer Security

Part 1: All household members

Names of all household members

(First, Middle Initial, Last)

Name of school for each child/or indicate "NA" if child is not in school

Check if a foster child (legal responsibility of welfare agency or court) * If all children listed below are foster children, skip to Part 5 to sign this form.

Check if NO income

Part 2. Benefits

If any member of your household receives [snap], [fdpir] or [tanf cash assistance], provide the name and case number for the person who receives benefits and skip to part 5. if no one receives these benefits, skip to part 3

Name

Case Number

Part 3.

if any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your child's school.

Homeless Migrant Runaway

PART 4.

Total household gross income. you must tell us how much and how often.

1. NAME

(List only household members with

income)

2. Gross income and how often it was received

Earnings From Work

before deductions

Welfare, child support, alimony

Pensions, retirement,

Social Security, SSI, VA

benefits

All Other Income

(Example) Jane Smith

$199.99/weekly

$149.99/every other week

$99.99/monthly

$50.00/monthly

Part 5.

Signature and last four digits of social security number (adult must sign)

An adult household member must sign the application. If Part 4 is completed, the adult signing the form also must list the last four digits of his or

her Social Security Number or mark the "I do not have a Social Security Number" box. (See Statement on the back of this page.)

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.

Sign here:

Print name:

Date:

Address:

Phone Number:

City:

State:

Zip:

Last four digits of Social Security Number: * * * - * * -

I do not have a Social Security Number

Part 6.

Children's ethnic and racial identities (optional)

Choose one ethnicity:

Hispanic/Latino Non Hispanic/Latino

Choose one or more (regardless of ethnicity):

Lunch program Please fill out the form below:

Lunch program
Please fill out the form below: