Private Schools

A PPENDIX E.1 APPLICATION DATA ABSTRACTION FORM

OMB Approval No.: 0584-0530

Approval Expires:

NSLP AND SBP ACCESS, PARTICIPATION, ELIGIBILITY, AND CERTIFICATION STUDY (APEC-II)

APPLICATION DATA ABSTRACTION FORM

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 0584-0530. The time required to complete this information collection is estimated to average 45 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collected.

NSLP AND SBP ACCESS, PARTICIPATION, ELIGIBILITY, AND CERTIFICATION STUDY (APEC-II)

APPLICATION DATA ABSTRACTION FORM

A. STUDENT INFORMATION			IF NOT COMPLETING SECTIONS B, C, AND D, MARK REASON BELOW
STUDENT: (Last Name, First Name)	MPR ID:		DIRECT CERTIFICATION STUDENT  APPLICATION CANNOT BE FOUND  COPY OF APPLICATION ATTACHED  OTHER REASON (Specify) 
SFA NAME AND ID #:
SCHOOL NAME AND ID #:	GRADE:

B. HOUSEHOLD INFORMATION AND CERTIFICATION STATUS: Complete the information below using the most recent school meal application completed 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/district staff.
1. APPLICATION DATE | | |/| | |/| | | MONTH DAY YEAR  Date Not Available	4. CERTIFICATION DATE | | |/| | |/| | | MONTH DAY YEAR  Data obtained from Secondary Source Source:_________________________  Date Not Available
2. BASIS FOR ELIGIBILITY  INCOME  CATEGORICAL CASE #:_____________________________  TANF  FDPIR  SNAP  Not Specified  FOSTER CHILD: Personal Use Income: $_________________  Income Not Listed  RUNAWAY  HOMELESS  HOMELESS  MIGRANT  INSTITUTIONALIZED  OBSERVED NEED	5. CERTIFICATION STATUS  FREE  REDUCED-PRICE  DENIED  TEMPORARY FREE  TEMPORARY REDUCED-PRICE Temporary Status Expires: | | |/| | |/| | | MONTH DAY YEAR  NOT RECORDED ON APPLICATION CERTIFICATION STATUS:___________________________
3. NUMBER OF STUDENTS COVERED BY APPLICATION | | |	6. SFA’S ASSESSMENT OF NUMBER OF PERSONS IN HOUSEHOLD | | |  Data obtained from Secondary Source Source:_________________________  Data not available
	7. SFA’S ASSESSMENT OF TOTAL INCOME $ | | |,| | | |  Monthly  Annual  Other _________________  Data obtained from Secondary Source  Data not available Source:_________________________

Please complete Sections C through E on the back

C. INCOME RECORDED ON APPLICATION FORMS: List all household members recorded on the application, including all students covered by application. Record income data for all persons receiving income exactly as shown on the application. Enter income denomination codes next to amounts under the “PER” column. W=Weekly; BW=Bi-weekly (every two weeks); SM=Semi-Monthly (twice a month); M=Monthly; Y=Yearly; OTH=Other (indicate period on form). If the period is printed in the column heading or instructions, rather than filled in by the applicant, then add “-DP” after the period code. If students covered by the application are not listed in the application’s income grid, list them in Section C, Column 1, enter $0 for their income, and initialize in the margin.

1.		2.		3.		4.		5.
LIST HOUSEHOLD MEMBERS		EARNINGS FROM WORK		WELFARE, CHILD SUPPORT, OR ALIMONY (NO SNAP)		PENSIONS, RETIREMENT, OR SOCIAL SECURITY		ALL OTHER INCOME
LAST NAME	FIRST NAME	AMOUNT	PER	AMOUNT	PER	AMOUNT	PER	AMOUNT	PER
1.		$		$		$		$
2.		$		$		$		$
3.		$		$		$		$
4.		$		$		$		$
5.		$		$		$		$
6.		$		$		$		$
7.		$		$		$		$
8.		$		$		$		$
9.		$		$		$		$
10.		$		$		$		$

D. FORM COMPLETENESS

	Yes	No
1. Was target child’s name listed?	1	0
2. If basis for eligibility is income, was income recorded for at least one household member?	1	0	N/A
3. If basis for eligibility is TANF, SNAP, or FDPIR, was case number recorded?	1	0	N/A
4. Was the form signed by an adult household member?	1	0
5. Was SSN of adult signer entered or an indication that signer does not have SSN?	1	0

E. ABSTRACTOR’S SIGNATURE AND MPR ID ____________________ |___|___| - |___|___|___|___|___|

DATE: | | | / | | | / | | | MONTH DAY YEAR

Prepared by Mathematica Policy Research