ADULT DAY CARE COMPONENT APPLICATION FOR FREE AND REDUCED-PRICE MEALS—INSTRUCTIONS 02/11 Please complete the Application for Free and Reduced-Price Meals using the instructions below. Sign the statement and return to the center. If you need help, call the center at _________________________________________________. Part 1: Participant’s Information: All households complete this part. Print the name of the adult enrolled at the center. Part 2A: Households getting Food Stamps, Supplemental Security Income (SSI), or Medicaid: Complete this part and Parts 3 and 4. 1. List the current food stamp number, SSI identification number, or Medicaid number for the participant. Do not complete Part 2B. 2. An adult household member must sign the application in Part 4. Part 2B: All Other Households: Complete this part and Parts 3 and 4. 1. Write the name of everyone in the household. “Household” means the adult participant and, if residing with the participant, the spouse and dependent(s) of the adult participant. 2. Write the amount of income received last month for each household member. This income is the amount before taxes or anything else is taken out. Put the income is the correct column to show where it came from, such as earnings, welfare, pensions, and other income. Refer to the examples on back for types of income to report. If any amount last month was more or less than usual, write that person’s usual income. 3. An adult household member must sign the application and give his/her social security number in Part 4. 4. Part 3—Racial/Ethnic Identity: Completion of the racial/ethnic section is not mandatory. You are not required to answer this question to get meal benefits. However, this information will help ensure that everyone is treated fairly. Part 4—Signature, Social Security Number, and Certification Statement: All households must complete this part. 1. All Applications for Free and Reduced-Price meals must have the signature of an adult household member. 2. The adult household member who signs the application must include the last four digits of his/her social security number. If he/she does not have a Social Security Number, write “none” or state that he/she does not have a Social Security Number. Households getting Food Stamps, Supplemental Security Income (SSI), or Medicaid do not have to list a Social Security Number. 3. The certification statement states that the food stamp, SSI, or Medicaid number is correct or that the income reported is complete and accurate. --continued on back-- TYPES OF INCOME TO REPORT Earnings from Work Other Income Wages/Salaries/Tips Earnings from a second job Strike benefits Disability benefits Unemployment compensation Interest/dividends Workman’s compensation Cash withdrawn from savings NET income for a self -owned business or farm Income from estates/trusts/investments Regular contributions from persons not living in the household Welfare/Child Support/Alimony Royalties/annuities Public assistance payments Rental Income Welfare payments Any other Income Alimony payments Child support payments Pensions/Retirement/Social Security Pensions Retirement income Social Security Veteran payments Supplemental Social Security Income Once properly approved for Free or Reduced-Price meal benefits, a household will remain eligible for those benefits for a period not to exceed 12 months.