135 SIXTH AVENUE	PHONE: 412-318-1053
PITTSBURGH, PENNSYLVANIA 15229-1291	FAX: 412-318-1431

VISIT NHSD ONLINE: www.nhsd.net

Dear Parent/Guardian:

Children need healthy meals to learn. North Hills School District offers healthy meals every school day. Breakfast costs
$1.50; lunch costs $2.50. Your child(ren) may qualify for free meals or for reduced price meals. Reduced price is $.30 for breakfast and $.40 for lunch. This packet includes an application for free or reduced price meal benefits, and a set of detailed instructions. Below are some common questions and answers to help you with the application process.

If you have received a NOTICE OF DIRECT CERTIFICATION letter for free meals, do not complete the application. But do let the school know if any children in your household are not listed on the Notice of Direct Certification letter you received.
1.	WHO CAN GET FREE OR REDUCED PRICE MEALS OR SPECIAL MILK?
•	All children in households receiving Supplemental Nutrition Assistance Program (SNAP) (formerly the Food Stamp Program) or Temporary Assistance for Needy Families (TANF) benefits are eligible for free meals.
•	Foster children who are under the legal responsibility of a foster care agency or court are eligible for free meals.
•	Children participating in their school’s Head Start program are eligible for free meals.
•	Children who meet the definition of homeless, runaway, or migrant are eligible for free meals.
•	
FEDERAL ELIGIBILITY INCOME CHART FOR SCHOOL YEAR 2018-2019	
Household size	Annual	Monthly	Weekly	
1	22,459	1,872	432	
2	30,451	2,538	586	
3	38,443	3,204	740	
4	46,435	3,870	893	
5	54,427	4,536	1,047	
6	62,419	5,202	1,201	
7	70,411	5,868	1,355	
8	78,403	6,534	1,508	
Each additional person:	7,992	666	154	

Children may receive free or reduced price meals if your household’s income is within the limits on the Federal Income Eligibility Guidelines. Your children may qualify for free or reduced price meals if your household income falls at or below the limits on this chart.

Your children may qualify for free or reduced price meals/milk if your household income falls at or below the limits on this chart.

2.	HOW DO I KNOW IF MY CHILDREN QUALIFY AS HOMELESS, MIGRANT, OR RUNAWAY? Do the members of your household lack a permanent address? Are you staying together in a shelter, hotel, or other temporary housing arrangement? Does your family relocate on a seasonal basis? Are any children living with you who have chosen to leave their prior family or household? If you believe children in your household meet these descriptions and haven’t been told your children will get free meals, call 412-318-1053 with questions.

3.	DO I NEED TO FILL OUT AN APPLICATION FOR EACH CHILD? No. Use one Free and Reduced Price School Meals Application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to: North Hills High School, Attn: Food Service, 53 Rochester Rd, Pittsburgh, PA 15229.

4.	SHOULD I FILL OUT AN APPLICATION IF I RECEIVED A LETTER THIS SCHOOL YEAR SAYING MY CHILDREN ARE ALREADY APPROVED FOR FREE MEALS? No, but read the letter you received carefully and follow the instructions. If any children in your household were missing from your eligibility notification letter, contact the NHSD Food Services office at 412-318-1053 immediately.

5.	CAN I APPLY ONLINE? Yes! You are encouraged to complete an online application instead of a paper application if you are able. The online application has the same requirements and will ask you for the same information as the paper application. Visit www.schoolcafe.com or visit the PA Department of Human Services website at www.compass.state.pa.us.
1.	
6.	MY CHILD’S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT A NEW ONE? Yes.  Your child’s application is only good for that school year and for the first few days of this school year. You must send in a new application unless the school told you that your child is eligible for the new school year.

7.	I GET WIC. CAN MY CHILDREN GET FREE MEALS? Children in households participating in WIC may be eligible for free or reduced price meals. Send in an application.

8.	WILL THE INFORMATION I GIVE BE CHECKED? Yes. We may also ask you to send written proof of the household income you report.

9.	IF I DON’T QUALIFY NOW, MAY I APPLY LATER? Yes, you may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free and or reduced price meals if the household income drops below the income limit.

10.	WHAT IF I DISAGREE WITH THE SCHOOL’S DECISION ABOUT MY APPLICATION? You should talk to school officials. You also may ask for a hearing by calling or writing to: Mr. David Hall, 135 Sixth Avenue, Pittsburgh, PA 15229.

11.	MAY I APPLY IF SOMEONE IN MY HOUSEHOLD IS NOT A U.S. CITIZEN? Yes. You, your children, or other household members do not have to be U.S. citizens to apply for free or reduced price meals.

12.	WHAT IF MY INCOME IS NOT ALWAYS THE SAME? List the amount that you normally receive. For example, if  you normally make $1000 each month, but you missed some work last month and only made $900, put down that you made $1000 per month. If you normally get overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income.

13.	WHAT IF SOME HOUSEHOLD MEMBERS HAVE NO INCOME TO REPORT? Household members may not receive some types of income we ask you to report on the application, or may not receive income at all. Whenever this happens, write a 0 in the field. However, if any income fields are left empty or blank, those will also be counted as zeroes. Be careful when leaving income fields blank, as we will assume you meant to do so.

14.	WE ARE IN THE MILITARY. DO WE REPORT OUR INCOME DIFFERENTLY? Your basic pay and cash bonuses must be reported as income. If you get any cash value allowances for off-base housing, food, or clothing, or receive Family Subsistence Supplemental Allowance payments, it must also be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. Any additional combat pay resulting from deployment is also excluded from income.

15.	WHAT IF THERE ISN’T ENOUGH SPACE ON THE APPLICATION FOR MY FAMILY? List any additional household members on a separate piece of paper, and attach it to your application.

16.	MY FAMILY NEEDS MORE HELP. ARE THERE OTHER PROGRAMS WE MIGHT APPLY FOR? To find out how to apply for SNAP or other assistance benefits, visit www.compass.state.pa.us, contact your local assistance office, or call 1-800-692-7462.
If you have other questions or need help, call 412-318-1053.
Sincerely,
Lindsay W. Radzvin

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:

(1) Mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights,1400 Independence Avenue, SW Washington, D.C. 20250-9410 (2) Fax: (202) 690-7442; or
(3)	Email: program.intake@usda.gov.

This institution is an equal opportunity provider.

2018-2019 Pennsylvania Household Application for Free & Reduced Price School Meals and Special Milk Program (Complete one application per household. Use a pen)

STEP 1 List ALL Household Members who are infants, children, and students up to and including grade 12 (if more spaces are required for additional names, attach another sheet of paper)

Definition of Household Member: “Anyone who is living with you and shares income and expenses, even if not related.”

Children in Foster care and children who meet the definition of Homeless, Migrant or Runaway are eligible for free meals. Read How to Apply for Free and Reduced Price School Meals for more information.

													

																				

													

																				

Child’s First Name	MI	Child’s Last Name

Grade
Enter HS for Head Start

Student? Yes	No

Check all that apply

Foster Child

Homeless, Migrant, Runaway

													

 	

STEP 2 Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP or TANF?

Case Number:  	

													

																				

If NO	>  Go toSTEP 3.	If YES >    Write a case number here then go to STEP 4 (Do not completeSTEP 3)	Write only one nine (9) digit case number in this space.

A.	

Are you unsure what income to include here?

Flip the page and review the charts titled “Sources of Income” for more information.

The “Sources of Income for Children” chart will help you with the Child Income section.

The “Sources of Income for Adults” chart will help you with the All Adult Household Members section.

Child Income
Sometimes children in the household earn or receive income. Please include the TOTAL income received by all Household Members listed in STEP 1 here.

B.	All Adult Household Members (including yourself)

Child income

$

How often?

Monthly

2x Month

Bi-Weekly

Weekly

List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total gross income (before taxes) for each source in whole dollars (no cents) only.
If no income is received from any source, write ‘0’. If you enter ‘0’ or leave any ﬁelds blank, you are certifying (promising) that there is no income to report.

Name of Adult Household Members (First and Last)	Earnings from Work
$

How often?	Public Assistance/Child Support/Alimony

Weekly	Bi-Weekly	2x Month	Monthly	Annual	

 	 	 		

					

$

How often?

Weekly Bi-Weekly 2x Month Monthly

				

				

Pensions/Retirement/ All Other Income

$

How often?

nthly

Month Mo

i-Weekly 2x

Weekly B

$				

					

				

$	$

				

					

				

				

$	$	$

				

				

$	$	$

					

				

X	X	X	

$	$	$

Total Household Members (Children and Adults)

Last Four Digits of Social Security Number (SSN) of Primary Wage Earner or Other Adult Household Member

X X

				

Check if no SSN

STEP 4	Contact Information and adult signature	MAIL COMPLETED FORM TO YOUR CHILD’S SCHOOL

“I certify (promise) that all information on this application is true and that all income is reported. I understand that thi s information is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal beneﬁts, and I may be prosecuted under applicable State and Federal laws.”
Street Address (if available)	Apt #	City	State	Zip	Daytime Phone and Email (optional)
 	 	
Printed name of adult signing the form	Signature of adult	Today’s date

INSTRUCTIONS Sources of Income

Sources of Income for Children	
Sources of Child Income	Example(s)	
- Earnings from work	- A child has a regular full or part-time job where they earn a salary or wages	
-	Social Security
•	Disability Payments
•	Survivor’s Bene ﬁts	-	A child is blind or disabled and receivesSocial Security beneﬁts
-	A Parent is disabled, retired, or deceased, and their child receives Social Security beneﬁts	
- Income from person outside the household	- A friend or extended family member regularly gives a child spending money	
- Income from any other source	- A child receives regular income from a private pension fund, annuity, or trust	

 	
Sources of Income for Adults	
Earnings from Work	Public Assistance / Alimony / Child Support	Pensions / Retirement / All Other Income	
-	Gross Salary, wages, cash bonuses
-	Net income from self- employment (farm or business)
* Reporting Annual Income is allowable for seasonal or self-employment
If you are in the U.S. Military:
-	Basic pay andcashbonuses (do NOT includecombatpay, FSSA or privatized housing allowances)
-	Allowancesforoff-base
housing, food, and clothing	-	Unemployment bene ﬁts
-	Worker’s compensation
-	Supplemental Security Income (SSI)
-	Cash assistance from State or local government
-	Alimony payments
-	Child support payments
-	Veteran’s bene ﬁts
-	Strike bene ﬁts	-	Social Security (including railroad retirement and black lung bene ﬁts)
-	Private pensions or disability benefits
-	Regular income from trusts or estates
-	Annuities
-	Investment income
-	Earned interest
-	Rental income
- Regular cash payments from outside household	

OPTIONAL Children's Racial and Ethnic Identities

We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children’s eligibility for free or reduced price meals.

Ethnicity (check one): Race (check one ormore):

Hispanic or Latino	Not Hispanic or Latino
American Indian or Alaskan Native	Asian	Black or African American	Native Hawaiian or Other Paciﬁc Islander	White

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 identi ﬁer 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 bene ﬁts for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.

m

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 bene ﬁts. 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.
* All Household Applications must be returned to your child’s school for processing.

Do not ﬁll out

For School Use Only

Confirming Official’s Signature (cannot be the Determining Official): 	Date: 	Signature of School Employee Completing Verification: 	Date: 	

Determining Official’s Signature: 	Date: 	

☐	Other Source Categorically Eligible

☐	Reduced ☐ Denied Reason: 	☐ Categorically Eligible

Eligibility: ☐ Free

Household Size: 	Date Withdrawn: 	

Total Income: 	Per : ☐ Week, ☐ Every 2 Weeks, ☐ Twice A Month, ☐ Monthly, ☐Yearly,

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12