Orange County School of the Arts FREE/REDUCED

Orange County School of the Arts
FREE/REDUCED-PRICE LUNCH PROGRAM / INCOME ELIGIBILITY GUIDELINES
July 1, 2016 – June 30, 2017
Household Size
Year
Month
Twice Per Month
Every Two Weeks
Week
1
$21,978
$1,832
$916
$846
$423
2
29,637
2,470
1,235
1,140
570
3
37,296
3,108
1,554
1,435
718
4
44,955
3,747
1,874
1,730
865
5
52,614
4,385
2,193
2,024
1,012
6
60,273
5,023
2,512
2,319
1,160
7
67,951
5,663
2,832
2,614
1,307
8
75,647
6,304
3,152
2,910
1,455
642
321
296
148
For each additional family member, add:
+
7,696
FAQs for OCSA’s Free/Reduced Lunch Program (FRLP)
How do I apply?
If you qualify, based on your annual income and household size as listed above, please print and complete an OCSA FRLP
application. To download an application, visit www.ocsarts.net/ApplyFRLP. Please complete ONLY ONE APPLICATION PER
HOUSEHOLD. We cannot approve incomplete applications. Please be sure to carefully complete all required information and sign
the form to avoid delays in approval.
Please return the completed application to:
OCSA Business Office
Becky. Parsons
1010 N. Main St.
Santa Ana, CA 92701
Return the completed application to the address above or by fax to 714-664-0463, or by email to [email protected] . If your
household currently receives FDPIR benefits, CalFresh, or CalWORKs your child may automatically qualify for benefits; however,
you MUST still return the form indicating that you are participating in these programs.
Who can get free or reduced price lunch?
Children in households getting CalFresh, CalWORKS, or FDPIR and most foster children (under the legal responsibility of a welfare
agency or court) can get free lunch regardless of income. Also, if your household income is within the limits on the Income Eligibility
Guidelines, your children can receive free or reduced priced lunch. Homeless, runaway, and migrant children may qualify for lunch
benefits, check with the school liaison for these circumstances. Children in households participating in WIC may be eligible for
lunch benefits. Children do not have to be a U.S. citizen to qualify for lunch benefits.
Are there any other items that may be free/discounted because my family is eligible for this program?
Yes, all OCSA students in a qualified family can receive free/discounted pricing on several school related items. For more
information see the FRLP Fee Schedule listed at www.ocsarts.net/FRLP.
Can my child choose any food item from the menu?
No. All students that qualify for FRLP will receive a free “Daily Special” meal from our cafeteria which includes an entrée, whole fruit
and milk or water. All a la cart menu items including breakfast items will be at their own cost. Visit www.ocsarts.net/FRLPmenu for
more information.
Will the information I submit on my application be checked?
Yes. You may be asked to submit proof of the information you provide at any time during the school year. You must include income
of all people living in your household, related or not (such as grandparents, cousins or friends). If you are a single parent residing at
your parent’s home, you must include their income on the application.
Who will know if my child is on this program?
All applications and records concerning FRLP shall be confidential, and shall not be open to examination for any purpose not
directly connected with the administration of this program. Those accessing FRLP information could include Administrators of OCSA
programs, such as the OCSA Food Service program, After-School Student Program, School Registration, Locker Rentals, Parking
Permits, AP Testing, Collage Transcripts, and Student Services, for which your family may qualify for free/reduced pricing.
If I don’t qualify now, may I apply again later?
Yes. You may apply at any time during the school year if your household size goes up or income goes down.
What if I disagree with the decision about my FRLP application?
You may ask for an explanation by calling or writing Becky Parsons at [email protected] or 714-560-0900, ext. 5535.
California Department of Education, May 2016
School Year 2016-2017 Orange County School of the Arts Application for Free and Reduced-Price Meals Complete one application per household.
Read the instructions included with Application on how to apply. Please print and use a pen. This institution is an equal opportunity provider.
California Education Code Section 49557(a): “Applications for free and reduced-price meals may be submitted at any time during a school day. Children participating in the federal National School
Lunch Program will not be overtly identified by the use of special tokens, special tickets, special serving lines, separate entrances, separate dining areas, or by any other means.”
STEP 1 – STUDENT INFORMATION
Children in Foster Care and children who meet the definition of Homeless, Migrant, or Runaway are eligible for free meals. Attach another sheet of paper for additional names.
Enter the name of EACH STUDENT who will attend school
Check the applicable box if the student is
Enter school name and grade level
Enter student’s birth date
(First, Middle Initial, Last)
foster, homeless, migrant, or runaway.
Foster Child
Homeless
Migrant
Runaway
EXAMPLE: Joseph P Adams
Lincoln Elementary
1st
12-15-2010
STEP 2 – ASSISTANCE PROGRAMS: CalFresh, CalWORKs, or FDPIR
Do ANY household members (including yourself) currently participate in one of the following assistance programs?
If NO, skip STEP 2 and complete STEP 3.
Select Program Type:
If YES, do not complete STEP 3. Check the applicable program
box, enter one case number, and then go to STEP 4.
 CalFresh  CalWORKs  FDPIR
Enter Case Number:
A. STUDENT INCOME: Sometimes students in the household earn income. Please include the TOTAL income earned by Total Student Income
How Often
all students listed in STEP 1 here. Report total income in whole dollars earned before taxes and deductions.
$
Enter the appropriate pay period: W = Weekly, 2W = Bi-Weekly, 2M = Twice a Month, M = Monthly, Y = Yearly
B. ALL OTHER HOUSEHOLD MEMBERS (including yourself): List ALL household members not listed in STEP 1 even if they do not receive income. For each
household member, report the TOTAL income for each source in whole dollars 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. Report all income earned before taxes and deductions.
Enter the appropriate pay period in the “How Often” column: W = Weekly, 2W = Bi-Weekly, 2M = Twice a Month, M = Monthly, Y = Yearly
Enter the name of ALL OTHER Household Members
How
Public Assistance/SSI/ How
Pensions/Retirement/
How
Earnings from Work
(First and Last)
Often Child Support/Alimony Often
All Other Income
Often
$
$
$
$
$
$
$
$
$
$
$
$
Enter the last four digits of Social Security number (SSN) from
the Primary Wage Earner or Other Adult Household Member
DO NOT COMPLETE. SCHOOL USE ONLY
Annual Income Conversion: Weekly x52, Bi-Weekly x26, Twice a Month x24, Monthly x12
How Often?  Weekly  Bi-Weekly  Twice a Month  Monthly  Yearly
Total Household Income
Total Household Size
 Categorical
Eligibility Status:  Free
Verified as:  Homeless
Determining Official’s Signature:
 Reduced-price
 Migrant
 Paid (Denied)
 Runaway
 Error Prone
Date:
Confirming Official’s Signature:
Date:
Verifying Official’s Signature:
Date:















STEP 4 – CONTACT INFORMATION & ADULT SIGNATURE
STEP 3 – REPORT INCOME FOR ALL HOUSEHOLD MEMBERS (Skip this step if you answered ‘Yes’ to STEP 2)
Total Household Members
(Children and Adults)

Certification: “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 (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.”
Signature of adult completing this form:
Print Name:
Today’s Date:
Phone Number:
Address:
City:
State:
Zip:
E-mail:
Check the box if
NO SSN

OPTIONAL – CHILDREN’S ETHNIC AND RACIAL 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):



Hispanic or Latino
 Not Hispanic or Latino
Race (check one or more):
American Indian or Alaskan Native

Native Hawaiian or other Pacific Islander
Asian


Black or African American
White
2016-2017 Orange County School of the Arts licitud de comidas gratis o a precio reducido
Llene una solicitud por hogar.
California Department of Education, June 2016
Artículo 49557(a) del Código de Educación de California: “Las solicitudes de comidas gratis o a precio reducido se pueden presentar en cualquier momento durante un día de clase. A los menores que participen en el Programa Nacional
de Almuerzos Escolares (federal National School Lunch Program) no se les identificará abiertamente con el uso de fichas, boletos o filas para servir especiales; entradas o comedores separados; ni por ningún otro medio”.
Anote TODOS los miembros del hogar que son bebés, niños o estudiantes hasta el grado 12 (si necesita más espacio para más nombres, adjunte otra hoja de papel)
¿Estudiante?
Sí
No
Inicial Apellido del menor
Primer nombre del menor
Los menores bajo cuidado
adoptivo temporal, y los que
cumplen con la definición de sin
hogar, inmigrante o se fugó del
hogar reúnen los requisitos para
recibir comidas gratis. Para obtener
más información, lea Cómo solicitar
comidas escolares gratis o a precio
reducido.
PASO 2
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Bajo
cuidado
adoptivo
temporal
Sin hogar,
inmigrante, se
fugó del hogar
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Marque todos los pertinentes
PASO 1
Definición de miembro del hogar:
“Cualquier persona que viva con
usted y comparta los ingresos y
gastos, incluso si no es su
pariente”.
¿Algún miembro del hogar (incluyéndolo a usted) participa actualmente en uno o más de los siguientes programas de asistencia?
Si respondió que SÍ > Marque la casilla del programa pertinente, anote el número de caso y vaya al PASO 4 (No llene el PASO 3)
☐ CalFresh
☐ CalWORKs
☐ FDPIR Número de caso:
Si respondió que NO > Llene el PASO 3
PASO 3
Anote sólo un número de caso en este espacio.
Declare los ingresos de TODOS los miembros del hogar (sáltese este paso si respondió que ‘Sí’ en el PASO 2)
A. Ingresos de los menores
¿Frecuencia?
Semanal mente Cada 2 semanas 2 veces al mes Mensualmente
$
del hogar anotados en el PASO 1.
B. Todos los miembros adultos del hogar (incluyéndolo a usted)
Anote todos los miembros del hogar que no anotó en el PASO 1 (incluyéndose a usted mismo) incluso si no reciben ingresos. Para cada miembro que reciba ingresos, declare los ingresos totales de cada fuente en
números redondos. Si no reciben ingresos de ninguna fuente, anote ‘0’. Si anota ‘0’ o deja los campos en blanco, está certificando (prometiendo) que no hay ingresos que declarar.
Asistencia pública/
manutención de menores/
¿Frecuencia?
Nombre de los miembros adultos del hogar (nombre y
Ingresos de trabajo
Semanalmente Cada 2 semanas
¿Frecuencia?
Semanalmente Cada 2 semanas
2 veces al mes Mensualmente
¿Frecuencia
2 veces por mes Mensualmente
pensión alimenticia
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Total de miembros del hogar
(Del PASO 1 y PASO 3)
PASO 4
Ingresos totales de
los menores
En ocasiones, los menores del hogar tienen ingresos. Incluya aquí los ingresos TOTALES que reciben todos los miembros
Para obtener más
información lea Cómo
solicitar comidas
escolares gratis o a
precio reducido.
La sección Fuentes de
ingresos de los
menores le ayudará a
contestar la pregunta
Ingresos de los
menores. La sección
Fuentes de ingresos
de los adultos le
ayudará con la sección
Todos los miembros
adultos del hogar.
Últimos cuatro dígitos del número de seguro social (SSN)
del principal proveedor o de otro miembro adulto del hogar
X
X
X
X
X
Pensiones/jubilación/
todos los demás ingresos
Semanalmente Cada 2 semanas 2 veces por mes Mensualmente
☐
Marque la casilla si no tiene SSN
Información de contacto y firma del adulto
Certificación: “Certifico (prometo) que toda la información en esta solicitud es verdadera y que he declarado todos los ingresos. Entiendo que esta información se proporciona en relación con la recepción de fondos federales y que los funcionarios escolares podrían verificar (revisar)
la información. Entiendo que si doy intencionalmente información falsa, mis hijos podrían perder los beneficios alimentarios y yo podría ser enjuiciado bajo las leyes estatales y federales pertinentes”.
Dirección
OPCIONAL
No. de departamento
Ciudad
Teléfono o correo electrónico
Estado Código postal
Identidad étnica y racial de los menores
Nombre en letra de molde del adulto que llenó este formulario
Firma del adulto que llenó este formulario
Fecha de hoy
Esta institución es un proveedor que ofrece igualdad de oportunidades.
Estamos obligados a pedir esta información sobre la raza e identidad étnica de sus hijos. Esta información es importante y nos ayuda a asegurarnos de que estamos sirviendo plenamente a nuestra comunidad. Responder esta sección es opcional y no afecta el cumplimiento de los requisitos de sus hijos para recibir comidas gratis o a precio
reducido.
Identidad étnica (marque una):
☐Hispano o latino ☐No hispano o latino
Raza (marque una o más):
☐ Asiático ☐ Indígena americano o nativo de Alaska ☐Negro o afroestadounidense ☐ Nativo de Hawái u otra isla del Pacífico ☐ Blanco
NO LLENE LA SIGUIENTE INFORMACIÓN. ES PARA USO DE LA ESCUELA SOLAMENTE.
How often?
Total Household Income Weekly Bi-Weekly 2x Month Monthly Yearly
Total Household Members
Annual Income Conversion
Weekly x52 | Bi-Weekly x26 | Twice Per Month x24 | Monthly x12
Determining Official
Date
Confirming Official
Approved as:
Verified as:
☐ Free
☐ Reduced-Price
☐ Paid (Denied)
Reason: ____________________________
Date
☐ Homeless
☐ Migrant
☐ Runaway
Verifying Official
☐ Categorical
☐ Error Prone
Date