Private Schools

Attachment F.1- CERTIFIED AND DENIED APPLICANT SAMPLING FORM

OMB Approval No.: 0584-0530

Approval Expires:

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

STUDENT SAMPLE CONTACT INFORMATION FORM FOR FREE\REDUCED-PRICE

AND DENIED APPLICANT SAMPLES

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 15 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collected.

NATIONAL SCHOOL LUNCH AND SCHOOL BREAKFAST PROGRAM ACCESS,

PARTICIPATION, ELIGIBILITY, AND CERTIFICATION STUDY (APEC-II)

STUDENT SAMPLE CONTACT INFORMATION FORM FOR FREE\REDUCED-PRICE

AND DENIED APPLICANT SAMPLES

SCHOOL DISTRICT ID NUMBER: | | | | | | | | | SCHOOL DISTRICT NAME:

SCHOOL ID NUMBER: | | | | | | | | | SCHOOL NAME:

DATE: | | | / | | | / | | |

MONTH DAY YEAR

I. FREE AND REDUCED-PRICE SAMPLE

	SAMPLE RESULTS
	A.	B.	C.	D.	E.	F.	G.	H.
	Student Number	Selection Order	Selection Type (M or R)	Student Name	Grade	Parent’s Name	Mailing Address	Telephone Number
1.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
2.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
3.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
4.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
5.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
6.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
7.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
8.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
9.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
10.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
11.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
12.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
13.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
14.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
15.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
16.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
17.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
18.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
19.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
20.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: Free Reduced Price		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR

II. DENIED APPLICANT SAMPLE

	SAMPLE RESULTS
	A.	B.	C.	D.	E.	F.	G.	H.
	Student Number	Selection Order	Selection Type (M or R)	Student Name	Grade	Parent’s Name	Mailing Address	Telephone Number
1.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: DENIED APPLICANT		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
2.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: DENIED APPLICANT		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
3.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: DENIED APPLICANT		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR
4.				First: Middle: Last:		First: Middle: Last:	Street: City: State: Zip:	( ) _________ _________
	I. Application Number: _______________________________			J. Certification Status: DENIED APPLICANT		K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR

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