NORTH HILLS SCHOOL DISTRICT
135 Sixth Avenue
Pittsburgh, PA 15229	
                                                       Phone: 412-318-1000  
Email: radzvinl@nhsd.net  Web: 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 eligible students will receive breakfast and lunch FREE. This packet includes an application for free and 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.
•	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. 	
	I		
INCOME ELIGIBILITY REDUCED PRICE GUIDELINES JULY 1, 2023-JUNE 30, 2024

			
Family Size	Annual	Monthly	Twice Per Month	Every Two Weeks	Weekly	
1	$26,973	$2,248	$1,124	$1,038	$519	
2	$36,482	$3,041	$1,521	$1,404	$702	
3	$45,991	$3,833	$1,917	$1,769	$885	
4	$55,500	$4,625	$2,313	$2,135	$1,068	
5	$65,009	$5,418	$2,709	$2,501	$1,251	
6	$74,518	$6,210	$3,105	$2,867	$1,434	
7	$84,027	$7,003	$3,502	$3,232	$1,616	
8	$93,536	$7,795	$3,898	$3,598	$1,799	
						
Each additional family member add:	+$9,509	+$793	+$397	+$366	+$183	
 
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 or email the NHSD food service office with questions at 412-318-1053.
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. You may request a paper application from the school at any time. Return the completed application to: North Hills High School, Food Service Dept, 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 Mrs. Margaret Labritz, 412-318-1053 or email labritzm@nhsd.net 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.
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 30 operating school 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.  The deadline for carryover eligibility from the previous school year is WEDNESDAY, OCTOBER 4, 2023.
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. Gerald Muth, 135 Sixth Avenue, Pittsburgh, PA 15229 or email muthg@nhsd.net.
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. Contact Mrs. Margaret Labritz at 412-318-1053 to receive a second 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 county assistance office, or call 1-800-692-7462.  
If you have other questions or need help, call 412-318-1053.
Sincerely, 
Lindsay Radzvin, Director of Food Service
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.
Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g.,Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.
To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted 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; or
2.	fax:
(833) 256-1665 or (202) 690-7442; or
3.	email:
Program.Intake@usda.gov
This institution is an equal opportunity provider.
ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Contact your child’s school. 
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Comuníquese con la escuela de su niño.

23-24 SY Pennsylvania Household Application for Free and Reduced Price School Meals
Complete one application per household. Please use a pen (not a pencil).

APPLY ONLINE: www.schoolcafe.com
RETURN TO: NHSD Food Service Office, 53 Rochester Rd, Pittsburgh, PA 15229

STEP 1  List ALL children, infants, and students up to and including grade 12. Attach another sheet of paper if you need space for more names.
List ALL children in the household. Do not forget to list infants, children attending other schools, children not in school, and children not applying for benefits. This includes children not related to you in your household.
Child’s First Name	MI	Child’s Last Name	Grade	Apply	Foster Child	Migrant	Runaway	Homeless	Application Instruction’s	
Click or tap here to enter text.	MI	Click or tap here to enter text.	Grade	Check all that apply	☐	☐	☐	☐	If you checked
any of these
boxes, please 
refer to the
Application
Instruction’s
Step 1: Part C & Part D.	
Click or tap here to enter text.	MI	Click or tap here to enter text.	Grade		☐	☐	☐	☐		
Click or tap here to enter text.	MI	Click or tap here to enter text.	Grade		☐	☐	☐	☐		
Click or tap here to enter text.	MI.	Click or tap here to enter text.	Grade		☐	☐	☐	☐		

STEP 2  Do any household members (including you) participate in: SNAP, TANF, or FDPIR?
	NO 	Go to STEP 3.		YES 	     	Write case number here and proceed to STEP 4. 		CASE NUMBER (NOT EBT NUMBER): Click or tap here to enter text.	Write only one case number in this space.
STEP 3  List ALL household members and income for each member (before taxes and deductions)
A.	All Adult Household Members (Anyone who is living with you and shares income and expenses, even if not related, including you.)
List all Adult Household Members not listed in STEP 1 (including yourself ) even if they do not receive income. For each Household Member listed, if they receive income, report total gross income (before taxes and 
deductions) for each source in whole dollars (no cents) only. If they do not receive income 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 received?	Public Assistance, 
Child Support, 
Alimony	How often received?	Pensions, Retirement, 
Social Security, SSI, 
VA Benefits, All Other 
Income	How often received?	
		Weekly	Every
2 Weeks	2x Month	Monthly	Annual		Weekly	Every
2 Weeks	2x Month	Monthly		Weekly	Every
2 Weeks	2x Month	Monthly	
Click or tap here to enter text.	$ Click or tap here to enter text.						$ Click or tap here to enter text.					$ Click or tap here to enter text.					
Click or tap here to enter text.	$ Click or tap here to enter text.						$ Click or tap here to enter text.					$ Click or tap here to enter text.					
Click or tap here to enter text.	$ Click or tap here to enter text.						$ Click or tap here to enter text.					$ Click or tap here to enter text.					
Click or tap here to enter text.	$ Click or tap here to enter text.						$ Click or tap here to enter text.					$ Click or tap here to enter text.					
Click or tap here to enter text.	$ Click or tap here to enter text.						$ Click or tap here to enter text.					$ Click or tap here to enter text.					

Total Household Members (Children and Adults)  Click here to enter text.
Last Four Numbers of Social Security Number of
Primary Wage Earner or other Adult Household 
Member (If Applicable) Click or tap here to enter text.
    
Check if no Social
Security Number ☐ 

Please see application’s back 
for list of income sources.
B.	 Child Income		Child Income	How often received?	
			Weekly	Every 
2 Weeks	2X Month	Monthly	Annual	
Sometimes children in the household earn or receive income.
Include the TOTAL income (before taxes and deductions) received by ALL children listed in STEP 1 here.		$Click or tap here to enter text.						
STEP 4  Contact information and adult signature.	RETURN COMPLETED FORM TO YOUR CHILD’S SCHOOL:	Insert school address here Click or tap here to enter text.
“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that school officials may verify
(confirm) 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.” 
 Click here to enter text.  
Print Name of Adult Signing the Form	
 Click or tap here to enter text.   
Signature of Adult 
 Click or tap here to enter text.	
Today’s Date
Click here to enter text.
 Mailing Address (if available) 
Click or tap here to enter text.
City 
Click or tap here to enter text.
State 
Click or tap here to enter text.
Zip 
Click or tap here to enter text.
Phone (optional)
Click or tap here to enter text.
Email (optional) 

SOURCES AND EXAMPLES OF INCOME  For additional information on income, please refer to the instructions that accompany this application.

Sources of Income
Earnings from Work	Public Assistance/Alimony/
Child Support	Pensions/Retirement/
All other sources of income	
•	Salary, wages, cash bonuses, tips, commissions
•	Net income from self-employment (farm or 
business)
If you are in the U.S. Military:
•	Basic pay and cash bonuses (do NOT include 
combat pay, FSSA, or privatized housing 
allowances)
•	Allowances for off-base housing, food, 
and clothing	•	Unemployment benefits
•	Workers’ compensation
•	Supplemental Security Income (SSI)
•	Cash assistance from State or local 
government
•	Alimony payments
•	Child support payments
•	Veterans’ benefits
•	Strike benefits	•	Social Security/Disability (including railroad retirement and black lung benefits)
•	Private Pensions or disability benefits
•	Income from trusts or estates
•	Annuities
•	Investment income
•	Earned interest
•	Rental income
•	Regular cash payments from outside household	

Examples of Income for Children
•	A child has a regular full or part-time job where they earn a salary or wages
•	A child is blind or disabled and receives Social Security benefits
•	A parent is disabled, retired, or deceased, and their child receives Social Security benefits
•	A friend or extended family member regularly gives a child spending money
•	A child receives regular income from a private pension fund, annuity, or trust

OPTIONAL  Children’s ethnic and racial identities. This information is kept confidential and may be protected by the Privacy Act of 1974.
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): ☐ Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin, regardless of race)	☐ Not Hispanic or Latino
Race (check one or more): ☐ American Indian or Alaska Native	☐ Asian	☐ Black or African American	☐ Native Hawaiian or Other Pacific Islander	☐ White
Return this completed form to your child’s school. *Do not mail, fax, or email completed applications to the U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights.   
 DO NOT FILL OUT  For school use only.
Annual Income Conversion: Weekly × 52, Every 2 Weeks × 26, Twice a Month × 24, Monthly × 12. Do not annualize income to determine eligibility unless more than one income frequency is listed.
Total Income
Click or tap here to enter text.

How often?
Weekly	Every
2 Weeks	2x Month	Monthly	Annual	

Household size
Click or tap here to enter text.

Categorical Eligibility ☐

Eligibility
Free 	Reduced	Denied	

Click or tap here to enter text.
Determining Official’s Signature

Click or tap to enter a date.
Date
Click or tap here to enter text.
Confirming Official’s Signature

Click or tap to enter a date.
Date
Click or tap here to enter text.
Verifying Official’s Signature
Click or tap to enter a date.
Date

Use of Information Statement ________________________________________________________________________________________________________________________________________________________________

The Richard B. Russell National School Lunch Act requires that we use information from
this application to see who qualifies for free or reduced price meals. We can only approve
complete forms. We may share your eligibility information with education, health, and
nutrition programs to help them deliver program benefits to your household. Inspectors
and law enforcement may also use your information to make sure that program rules are
met.
Please be sure to provide the last four numbers of the Social Security number of the adult 
household member who signs the application. If the adult does not have one, ‘Check if no 
Social Security Number’. Applications for a foster child do not need to list a Social Security 
number. Applications for children in households receiving Supplemental Nutrition 
Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) or Food 
Distribution Program on Indian Reservations (FDPIR) do not need to list a Social Security 
number.
Some children qualify for free meals without an application. Please contact your school to
get free meals for a foster child, and children who are homeless, migrant, or runaway.
Return completed form to your child’s school.
The contact information below is solely to file a complaint of discrimination
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited 
from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or 
retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.
To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form 
which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s 
name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted 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: 	 (833) 256-1665 or (202) 690-7442; or 
EMAIL: 	 Program.Intake@usda.gov 
	* Do not mail applications to
this address, only complaints
of discrimination.	
This institution is an equal opportunity provider