State, Local & Tribal LEA Schools

CEO C_3 Application Data Form

OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX

Community Eligibility Option Evaluation

Application Data Form

INTERVIEWER NOTE: Introduce yourself to the respondent. Remind them of the reason for your visit (refer to advance letter if needed). Review informed consent paragraph from the advance letter; and give them a copy of this letter.

A. Student Information

	Copy information in this column from the Certification Record Abstraction Form and see if it matches the application
LEA ID #:	LEA Student ID #:
LEA Name:	Abt Record ID #:
School ID #:	Application ID #:
School Name:

B. Household Information and Certification Status:

Complete this column using the most recent school meal application for school year 2012-2013 for the student named in Section A	Complete this column based on information from the section of the application completed by school/LEA staff or LEA application database
APPLICATION DATE |___|___|/|___|___|/|___|___| Month Day Year Date Not Available	4. CERTIFICATION DATE |___|___|/|___|___|/|___|___| Month Day Year Date Not Available
BASIS FOR ELIGIBILITY Income Categorical Case No of digits of Categorical Case #: ________ TANF FDPIR SNAP/FOOD STAMPS Not Specified Foster Child Personal Use Income: $ ________ Income Not Listed Runaway Homeless Migrant Institutionalized Observed Need/No Income/Temporary	5. CERTIFICATION STATUS Free Reduced-Price Denied Not Listed
	6. LEA’s basis for eligibility determination Income Eligibility Categorical Eligibility Not Listed Not Applicable (if checked, skip questions 7-9 and go to part D)
NUMBER OF STUDENTS COVERED BY APPLICATION |__|__|	7. LEA’S ASSESSMENT OF NUMBER OF PERSONS IN HOUSEHOLD |__|__| Not Listed
	8. LEA’S ASSESSMENT OF TOTAL INCOME $ __________________	Weekly Bi-weekly Semi-monthly Annual Not Listed Other: ________

Please complete Sections C through E on the back 

C. Household Composition and Income

List all household members recorded on the application by their initials, including all students covered by application. Record income data for all persons receiving income exactly as shown on the application. Circle income period codes next to amounts under the “PER” column. W=Weekly; B=Bi-weekly (every two weeks); S=Semi-Monthly (twice a month); M=Monthly; Y=Yearly; O=Other (if Other, write period on line). If students covered by the application are not listed in the application’s income grid, list them in Column 1 and check the box in column 1a. If more than 10 people are listed, use an additional Application Data Form to capture the household composition and income.

1.	1a.	2.	3.		4.		5.		6.
LIST ALL HOUSEHOLD MEMBERS’ INITIALS	PERSON NOT LISTED	INCOME LISTED	GROSS EARNINGS FROM WORK		WELFARE, CHILD SUPPORT, OR ALIMONY		PENSIONS, RETIREMENT, SOCIAL SECURITY, SSI, VA BENEFITS		ALL OTHER INCOME
			AMOUNT	PER	AMOUNT	PER	AMOUNT	PER	AMOUNT	PER
1.		Not Listed No Income	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________
2.		Not Listed No Income	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________
3.		Not Listed No Income	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________
4.		Not Listed No Income	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________
5.		Not Listed No Income	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________
6.		Not Listed No Income	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________
7.		Not Listed No Income	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________
8.		Not Listed No Income	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________
9.		Not Listed No Income	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________
10.		Not Listed No Income	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________	$	W B S M Y O:_________

W = Weekly; B = Bi-weekly; S = Semi-monthly; M = Monthly; Y = Yearly; O = Other (specify)

D. Form Completeness

	YES	NO	NOT APPLICABLE
If the basis for eligibility is income, was income recorded for at least one household member?	1	0	8
Was the form signed by an adult household member?	1	0	8
Were the last 4 SSN digits of adult signer entered or did signer indicate that he/she does not have SSN?	1	0	8

E. Abstractor Abt ID: __________________________________ DATE: |__|__|/|__|__|/|__|__|

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection is 0584-XXXX. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collected.

MONTH DAY YEAR

Application Data Form 1