DRACI.]"| PUBLIC SCHOOLS LUNC}I PROGRAM I54O LAKEVIEW

DRACI.]"|PUBLIC SCHOOLS
LUNC}I PROGRAM
I54OLAKEVIEWAVENUE
DRACUT.MA 01826
StevenStone
Superintendentof Schools
MichaelMaguire
FoodServiceDirector
(978) I 57-9714
Telephone
Fax(978)957-6538
Dear Parent/Guardiao:
costs
mealsto learn.l)racrrt Public Schonleoffershealthytnealseveryschoolday'Breakfast
Childre' needl.realthy
mnt'
childrerr
Your
I.urrch
$2'50'
Sc,:onelart'
$2"25,
l,,unch
r;osrs
lilemcntary
$1.00(Irarker A'enue School);lunch
priceis $,30 for brer&fastand$'40 for lutrch'
q.r.lrFyfo, freernealsor Fcrrreducedpric,:meals.Reduced
1.
z.
3.
4.
5.
6.
1.
tC'I
APPIiCAIiON
tITC
NO.COMPICTC
DO I NEED TO FILL OUT r\N APPLICATION FOR EACH CHILD?
MealsApplication.fotall.srudents
applyfor freeor reducedpricemeals.UseoneFreeandReducedPriceSchool
b.
sureto fill out all required
t-g
comprlete,
is
not
that
tJre
househoid. cannotapprovean application
d;;*
1540l-akcvicru Aventre'
Program,
Lurnch
$chool
Rerumthe compleiedapplicatitnto: Dracut
in6ortnation.
Dracut,MA 01826.
receivingbenefitsfrom MA SNAP'MA TAIiD(wHO CAN GET FREE MEA.LS?All childrenin households
of your inconre'Also'
program
fre,qmealsregardless
can
get
on IndianReservations,
or theFoodDistribuuon
limits
on the FederalIncome
free
the
within
is
income
gross
your childrencangerfr"" meilsif your household's
EligrbiliryGuide[nes'
ol}egalresPonsi[ifu6'
cAN FOSTL,RCI{iLDRll,N GH,TFREEMEALS? Yes,fostefchildrentharareunderthe
rr-reals
ftee
f<rr
is
eligible
household
in
the
child
foster
a fostercareagencyor court,aree[giblefor freemeals.Any
of income.
regarc{less
TVh<T
CITiIdTCN
CAN HOMELESS,RUNAW;\Y, AND MIGRAN'I CHILDREN GET FREE ME'ALS?YCS,
children
your
told
been
haven't
If
you
als.
me
free
for
or rni.gmntquaiify
runaway,
meerrhedefiniuonof homeless.,
callor e-rnailDeborah Koniowka, homclictisliaison, c-rnail
will setfreemeals,please
to seeif theyqualify'
call 978-459-6186
dkoli<,y*l<[email protected]
income
household
if
WHO CAN GET REDUCED PRICEMEALS? Your childrencan{letlow costmeais your
application'
on
this
shown
is within the reducedpricelimits on the FederalEligrbrhtyIncomeChart,
SAYING
SI{OULD I FILL OUT AN AI'PLICATION IF I RECEIVED A LIJTTER THIS SCHOOLYEAR
follow the
and
catefully
got
letter
you
the
Nry CHILDREN ARE APPROVED FOR FREE MEAIS? Pleaseread
questions.
have
Cafeteria Office if you
insrrucuons,Callthe schoolat918-957^9714
FILL OUT ANOTHER
My CHILD'S APPLICATION WAS APPROVEDl-\ST YEAR. DO I NEED TO
.lthis school
fust
for
the
and
is onlygood for that schoolyear
ONE? yes. your child'sappli,:ation
f1i19^y^t
thenewschool
for
is
eligible
child
unles,the schooltoid you thatyour
year.you mustsendin a n.* aLpplicarion
year.
fJ,
may
in \xi'TC
participating
I GET\X'IC. cAN MV CHILD(REN) GET FREE MEALS? Cirildrenin households
be eligrbleForfreeor reducedprricemeals-PleaseFrllout an applicati'rn.
g.
alsoaskyor-rto sendwrittenprr'of
WILL THE INFORI{ATIO}{ I GIVE BE CHECKED? Yesandwe may
10.
at anytlmeduringthe-school
IF i DON'T QUALIFY No\M, MAY I APPLY LATER? Yes,yorrmayapp\'
may becomeeligibleForFreeand
year. For **u,o*pl*,chrldrenwrth a parentor guardianwho becomesunemployed
reducedprlcemealsif the householdincomedropsbelov.tthe incomelirmt.
l1
I a.
!i'FIAT IFI I DISAGREE WITII TI{E SCI""IOOL'SDECISION AI]OUT N{Y A]]PLICA'TION? YOIISIItItIId
of
You also may ask for a hearingby cnliingor wriung to: StevenStone,SuperintenclenI
talk t6 schoolofflrcials.
or
e-rnail
978-957-2660
or
01826
MA
Dracut,
Avenue,
Sclrcroland/or designee,2063 Lakeview
[email protected].
MAY I APPLY IF SOMEONE' IN MY HOUSEHOLD IS NOT /T U.S. CITiZEN? YCS.\'OU OI VOUT
chilct(ren)do not have to be U.S. citizens to qualify for free or reducedptice rneals'
IiT'iTigiLI
Aii PCOPIC
WHO SI{OULD I INCLUDE AS MEMBERS OF MY HOUSEHiCLD? YOUNrUStiNCIUdC
expcnses
and
incorre
share
who
or
friends)
relatives,
other
'our househoid,related or not (such as grandparents,
yo' n r.,.,include yourself and alllchildlen Uvlng with you. If you hve widr other people who nre economically
clrilclrcrr'
independent(tor e-xample,peopie who you do not support,who do not shareincome rvith ycluot \:our
them'
and wl,o pay a pro-rated shareof expenses),do not include
14.
l )
l6
lror
WHAT IF l\,fy INCOME IS NOT ALWAYS THE SAME? List th,eamount that you normal\' receive.
nrade
ottll'
nncl
$9()0,pLrt
example,if you normally make $1000 eachmonth, but you missedsonrework last rnontlr
orrlv
it
iF
yor-r
include
do
not
dorvn'that y'ournndegtitOOper rnonrh. If you norrnally get overtin"re,include it, but
w o r k o r . , e r f i ' r e s o m e t i m eisf r. 1 r o u 1 . I . tl .o s t a j o b o r h a d y o u r h o u r s o r : w n g e s r c d q c e d , u $ c y o u r c u r r e n t i n c o n r c
II
WI] ARF, IN TI-Its,Mii.ITAR\'. DO \\iE INCLUDE OUR HOUSiING ALLOWi\NCE AS INCON{F)?
thc
is
of
it rnust be included as income. FIowever,if your housit-ig 1:ar:r
):ou get an off-base housing allo.'pance,
do not include y,ourhousingnllowanceas income.
Initiative,
Privatization
I{ousing
iv6ir"a'
NfI SPOUSE,IS DEPLOYED TO A COMBA'T ZONE, IS I-IER COMBA'I ]IAY COL]N'I'F]D T\S
il rvasrt't
INCOME? No, if rhe combatpay is receivedin additionto her basicpay becauseof [rerdeplolnneutand
trrote
lt<>r
receivedbefore she was depioyed,combat pay is not countedas inconre. Contact vour schr:ol
in formauou,
17
FOR?'I"TI
MY FAMILY NEEDS MORE, HELP. ARE THERE OTHER PROGRAMS WE IV{IGHT APPLY
cnl]
the
or
office
benefits,contactyour localassistance
find out lrow to apply for MA SNAP or other assistance
I{A SNAP Hotline 1-f}66-950-.1;(16.1
If you have other cluestionsot need help. call 978-L)57'97L4'
Si necesitannrda,por favor llame al tel6foncl:978'957'9'714'
Si vous voudriez d'aide,contacteznolrs ttu numero: 978'957'9'lt4
Sincer,eli)
/'J
,- J/.V
,.eq
/
,a1
I
Y*-l*
Michae{ NIaguirc,
F'oodServicebirector
pruc' scuoor-Mrlnrs HousE'om Appi'lcAltloN
MnssacHus',trsFnpr ANo Fr.souceo
Sct{ool-YEAR2012- 2013
7
t;hts
from rrreschoordiiimff for [r:eemeals'do trot cr:mplete
a NC)TICE OF DIRECT CEK|TFICATION
Ir Vou rrar,ereceivecr
certificntion leruer
i' the householdare n.t iistedcxrtlre Notice of Ditect
applicario^,Llurdo let 'he schoolknow if anvchjlclren
y0u receirrsi
,*k*g
'ART
Li'ngirrh.,,. Ai;r:;;;;.-";r;;fiil'r;+iliei'd;
r:hitdren
N.ttuit't ll, ALL I {()usl':lI()l,l) lvlllMul:ills
(l;irst,i\tiddlclrritial.Iast)
PIL TZ.
filre t"*;. 'iv:"f==:d
CIltillK tlr A FosrER CHILD (r.l(;.\r
()F s()-l(x)}.(lllll,t) dfiliNl)s
NAl,,,tfi
\(il:)i('\' ()R(1)trR'l)
l\' Ol;\1'[,l.lr:\Rt1
IttiSP()NSllll|.l
* Iti i\tl. (:l'Ill-DltttN l.ls I'1il) B[t].ow Allll
l ( ) S f I r l t ( l l I l l , l ) l l l i N , S K IP ' l ( ) P " U {l ' 5 '
MlGtutNT, RUN;\W'"\Y
FART 3. HOI\{ELESS,
BENEFITS- MA SNAP OR MA T'{FDC
MA SNAPot:
re al\ry ire\ffiERor YouR I{ousEHoLDRECEIVES
IDENTIFICATION
NIA'I' AIrtDC l>cncfits, PROVIDE THE AGEINCY
Ntj\IBE,R*LOCITEDoNTHEDEPARTNIENToFTL{NSiTIONAL
TO PART 5 AND
,rr;stsr'-rNCE (DTA) BENEFIT LETTER' SIIIP
AN AGENCY ID
PRO\IIDED
HA\IE
YOU
IF
SI(;N TF1ISTTORI\f
N LIIIBER.
Do n,ot provide EBT card number'
AI3ENCYID:
l . l \ . '\ i \ l l :
r.hool meals, silllir:.gsand ltioth parents of
I F A N Y C H i L D Y O U . \ R I " , . \ P P L Y I N G[ ' O I i I S
HO\,IELESS,A RUNAW'\Y, OR I\{IGRANl-'
CI{ECK TI-IE APPROPRIATEBOX,\ND C.\I,1,
I)erb,ltahKoniorvka,homelessliaison, rtr ruigtanl
coor<lirrator at 97tl-459'6186.
HOMELESS N I{UNAWA}: O
\{IC;R,\N'T II
i . < ; n o s sI N ( l o M t iA N I ) I I o w ( ) l / l ' l i NI ' l ' w ' \ Sl t l i ( ' J i l v l ' ) t )
( r , r s ' l ' o N L Yl l ( ) U S :l l l ( ) l , l )
I l , : \ ll J l ' ; l { s\ } ' ' l ' l ' Il l N ( . ( ) N { l ' )
Ail other income (Yott
mus,t indicate how rnuch
and how ofterr)
50
on thebackof'thispage'
litaternent
liisr here:
,-\dcl:ess:
PhoneNun-rber
[.,astfor-rrcirgrtsof SocialSecurin'Numbe r
Date
Pnnt Name:
State: .-..--_
Cin':
Zrp Cocie:
Ceil Phone
*""'ott
n Check here i[ t,ou do uot irave :r SocialSecur:rq'
---* _ - - i
f*e f't*. and ReducedPrice SchoolMeal Application
S c h o oY
l e a r2 0 l 2 - 2 4 1 3
ofethnicij):
Chooteont or moreftegardhts
O Asian
[ \Yvhite
AmcticanIndian or AlaskaNativr:
Illack or ,\frican i\mcr:ican
O Native Hawaiianor othcr Pacificllslandcr
TuriceAMonthx?4, Monthly x 12
Annual Incoirre Conversion:-Wee x 52, Every \Weeksx
E Every2 Weeks,B Twice A lvfonth,E lv{onth,I Year: I{ouseholdsize:
Pet: D V7eek,
Total Income:.-----Cateqorical Ehgrbiliq': --
Date $?ithdrarvn:
Free-
Reduced_-
Denied-*
DeterminingOfficial'sSignature:
signature:
C o n frim i n gO f f i c i a l 'S
VerifyingOfficial'sSignature;
Rea$on:
Date:
Your chilclrcnmay qualify frrr frec or reduccdpricc rncalsif your householdincome fallsat or
l:clowtlrc limrtson thischarr.
l.'F:I)lrlllAl.lil,l(; Illll,l'l'Y lN( l( )Ml': (:l t.\ R'l
Scho<rlYcar 2012-2011
Iouscholdsizc Ycarly
Use of Information
Statement: This explains hou' we will use the information
'l
you give us.
hc l{ichard B. l{usscll NrrtiorralSchrxrl Lunch ;\ct rccluircsthc informatiorr on this application.
Y o u r k r r r o t l r a v ct o g i v c d r c i r r f , r r m a i i o r rb, u t i f v o t r d o n o t . w c c e r l r l ( )nt p p r ( ) v cv t l u r c h i l d f r r r
t i ' c r , o r ' r c d u c c d p r i c c m c : r lYs o. u m u s t i n c l u d c t h c l a s t t i r u r c l i g i t s o f t h c s o c i sa cl c u r i t y ' u u m b c t
'l'hc
s r r c i asl c c u r i t yr r u m b c ri s n r t t
o f t h c ' a t l u l t h o r r s c h o l dm c m b c r w h o s i g n st b c a p p l i c a t i o n .
rcrluircrl wlren you apply on bchallof a firstcr child r.rryou list'a Supplcmcntal Nutr:itrori
. \ s s i s f a r r c lc) r o i l t i r m ( S N ' \ l ) " ' l c m p o r a n ' ' \ s s i s t a t i c cl : t r rN c c d y I r a m i l i c s( l ' ' \ N l r ) l ) r o g r a mo r
l ; r x r r l [ ) i s t r i b u r i o r rl ) r ' o g l l m o r r l n d i a n l l c s c n , a t i o n s( l r l ) l ) l l { ) c a s cn u m b c t r x o t h c r l r l ) ] ) l l {
rclcrrrificrfrrr vour child or whcn you indicatc that thc adult houschold mcmbcr signing thc
npplrcntion docs not havc a rurcialsccurity nurnbci. Wc will use yclur infrrrmation to determinc if
of
),our child is cligiblc tirr frcc or rcduccd pricc mcals, and for adrninistrationand cnfrrrccmcnt
infrrrmafi<tnwith cdr-rcation,
{lrc lurrch and brcakfist f rogram!i.We MAY shareyour chgnbil.iq,
hcnlrh, zrnclnutritiou pr()gralnsnr help thcm cvaluatc,tund, or dctcrmirrebenefits for thcir
pr{)gralns.auditors f<rrprrgrarn rcvicws, and law cnfa:rcementofftcials to help thcm look int<l
Morrthly
1 1)\
I
$20,665
7
927,991 $2.333
Wcckly
398
$539
3
$35.317
i) qa!
4
$42.(t43
t3.55{
s 8 2I
$49,969
s 4 ,615
5961
6
qq? r0q
4.775
$ I . 1f ) 2
7
s 6 4 . 6 2 1 5.186
s 1.243
l iach
aciditional
$71,947
$5.99(r
1.384
$7,326
s611
t4l
Pcfsofl:
violatiorrs of prrtgram nrlcs,
'I'his
explains what to do if you believe you have been treated unfeirly. "ln accordancc with lrcderal l,aw and Ll.S.
Statement:
Non-discrimination
I)cpartmcntofAgricu1turcp<>licy,thisinstitutionis1lr<lhibiteflom
ti|cactlmpIairrt<lfdiscriminatitln.wfitcUSI)A,I)ircct<lr'()ffccofAdjudicati<ln,1400|ndcpcrrdcnccr\vctruc.SW.Washingtrln.l).C.20250.9
ttllllicc(866)632.9992(\/<licc).lndividualswhtlarehcaringimp,airedor,havcspccch
( 8 0 0 ) 8 ? 7 - 8 3 3 9 r o r ( 8 0 0 ) 8 4 5 - 6 1 3 6 ( S p , a n i s h )L. I S I ) / I i s a n c q u a l ( ) p p o r t u n i t v p r o v i d c r a n d c m l l o v c r
MA Freeand ReducedPrice SchoolMeal Application
SchoolYear20I 2-20I 3