Household - 7 CFR 245

Attachment J23. Prototype Household Application for Free and Reduced Price School Meals Iu Mien
This information is being collected from School food authorities and schools. This is a revision of a
currently approved information collection. The Richard B. Russell National School Lunch Act (NSLA) 42
U.S.C. § 1758, as amended, authorizes the National School Lunch Program (NSLP). This information is
required to administer and operate this program in accordance with the NSLA. Under the Privacy Act of
1974, any personally identifying information obtained will be kept private to the extent of the law.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0584-0026. The time required to
complete this information collection is estimated to average 6 minutes per response. The burden consists
of the time it takes for households to complete their application. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 1320
Braddock Place, Alexandria, VA 22314, ATTN: PRA (0584-0026). Do not return the completed form to
this address.

OMB Control Number 0584-0026
Expiration Date: XX/XX/20XX

2016-2017: Ou Yu fi sen iin an get Frii an Kot Prais Fuud ina Skuul: Wi a Shuo Yu Ou fi Dwiit.
Fi evri ous, a dis wan faam fi ful out. Du, yuuz pen an, wi beg yu,no yuuz pensl.

Rait dong di niem a evribadi ina yu ous we a biebi pikni, pikni, ar yuut we go a skcuul rait op tu Gried 12 (if yu waahn spies fi rait dong muor niem, get wan neda piepa an wen yu don rait dong di ekstra niem dem, yu klip i pan di faam.)

Wen yu taak bout smadi we liv
a yu ous, wa dat miin?: “Dat a
enibadi we a liv ina yu ous an yu
an dem tek moni we unu bring
iin, an spen fi ron tingz ina di
ous. Yu an dem no afi bi fambli.”

Di Pikni Fos Niem

Ml

Wich Skuul Gried
Dem de ina

Di Pikni Laas Niem

A wan skuul
pikni dis?

Yes

Nuo

Pikni we di govament a luk
aafta an rispans fa (Foster
children), an pikni we yu kyan
se no av dem uona yaad fi liv
ina (Homeless children), pikni
we chravl fram wich paat dem
liv fi go liv a wan neda plies
(Migrant children), pikni we ron
wie fram dem uona
yaad.(Runaway)

NOMBA 2

> Go a NOMBA 3

Kies Nomba:

IF DI ANSA A YES > Rait di kies nomba ya so, an den go a Nomba 4
(Yu no fi bada wid Nomba 3)

Rait dong onggl wan kies nomba ya so.

Rait dong omoch moni a kom iin fi evribadi we liv ina di ous (No bada wid dis ya wan if yu did se ‘Yes’ a Nomba 2)
A. Moni we kom iin fi di pikni dem

Di Moni we kom iin fi

di pikni dem

It kyan apm se di pikni dem ina di yaad wok fi moni ar moni kom iin fi dem. If dat a gwaan, du, mek shuor se yu rait dong di ful

moni we di smadi dem we liv a di yaad an we niem rait dong a NOMBA 1, wok fa.

Yu no shuor wich moni we
kom iin yu fi rait dong?
Wel, ton uova dis ya piej an luk
pan di chaat dem we maak,
“Wich paat moni we kom iin a
di ous kom fram” so yu kyan
nuo we fi rait dong.

Di moni kom iin evri wa?
Wiik?

Tuu wiik?

Aaf mont?
Mont?

$

B. Aal di Big Piipl ina di Ous Dem Niem (aal fi yu niem)

Rait dong di niem dem fi aal di piipl we liv a yu yaad we no rait dong ina NOMBA 1 (aal fi yu niem) iivn if dem no bring iin no moni. Fi evri wan niem we rait dong, yu fi se omoch moni dem bring iin, if dem bring iin moni.
Yu fi rait dong di ful moni dem get (dat a di moni dem fi get bifuor di taks tek out) fram wicheva plies dem get i, wan bi wan. Dis rait dong di dala dem, an no bada wid di sent dem. If dem no get no moni fram nowe, rait
dong ‘0’. If yu rait dong ‘0’ ar lef blangk spies, dat miin fi se yu a komit yuself se no moni naa kom iin fi yu rait dong.
Evri Wa?
Omoch Moni dem Wok fa?

Big Piipl ina Di Yaad dem Niem (Fos an Laas)

Di chaat we maak “Wich Paat
di Moni fi di Pikni dem Kom
fram” wi elp yu wid di moni
we kom iin fi pikni.
Di chaat we maak “Wich paat
moni we kom iin fi big piipl
kom fram” a go elp yu wid di
paat a di faam we diil wid Aal
di Big Piipl dem we liv a di
yaad.

Wiik?

Tuu wiik?

Aaf mont?

Elp-Out fram Govament/ Moni fi
Main Pikni/ Divuors Moni

Mont?

Penshan/ Ritaiyament
Moni/ Eni ada moni we
kom iin

Evri Wa?
Wiik?

Tuu wiik?

Aaf mont?

Mont?

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Di Laas Fuor Figa dem ina di Suoshal Sikyuuriti Nomba
(SSN) fi di Smadi we Bring iin di muos moni ina a di ous,
ar wan Neda Big Smadi we liv de.

Omoch Piipl Liv a di Yaad
(Pikni an Big Piipl)

NOMBA 4

Di Pikni: No av dem uona
ous fi liv iina, / A Chravl
fram wich paat dem liv
go liv a wan neda plies, /
Ron wie fram dem yaad

Yu ar eni a di smadi dem we liv a yu ous a get elp fram wan a dem ya elp-out pruogram : SNAP, TANF, ar FDPIR?
IF DI ANSA A NUO

NOMBA 3

A wan pikni di
govament rispans
fa an smadi a
main?

Tik aaf evriting we fit di pikni

NOMBA 1

X

X

X

X

Evri Wa?
Wiik?

Tuu wiik?

Aaf mont?

Mont?

Maak ya so if
nobadi no av
no SSN

X

Tel wi ou wi fi fain yu. Den wan big smadi afi sain.

“Mi a tek uot se evriting we rait dong ya so pan dis ya faam chruu an a no lai, an mi rait dong evrii piis a moni we kom ina di ous. Mi andastan se mi a rait dis dong kaaz mi waahn get moni fram di Federal Govament. An mi nuo se di afisa dem fram di skuul a go chek out we mi se. Mi andastaan
se if mi nuo we mi rait dong a lai, an dem fain out, mi pikni wuda laas di elp wid di skuul fiidn pruogram an mi kyan get chaaj fi eni lai mi tel, azkaadn tu we di Federal and Stiet laa se.”

We yu liv? Schriit,(If yu nuo)

Apt #

Rait out, leta bi leta, di niem a di big smadi we a sain dis ya faam

Siti

Di big smadi we a sain fi sain ya

Stiet

Zip

Fuon nomba we wi kyan get yu pan a dietaim. An iemiel ajres (if yu av wan)

Di diet tude

WE YU FI DU

Wich Paat moni kom iin fram

Wich paat di big piipl dem get dem moni fram

Wich paat di pikni dem get dem moni fram

Moni dem wok fa

Laik

Wich Paat Pikni Get dem Moni Fram
- Moni yu wok fa

- Wan pikni av wan ful-taim jab ar wan paat-taim jab
we a pie moni

- Suohsal Sikyuuriti
- Moni fi uu sik ar kyaahn elp demself
- Moni fi uu av fambli we ded gaan lef
dem

- Wan pikni we blain ar badi no iebl an a get elp fram
Suoshal Sikyuuriti
- Wan mada ar faada we badi no iebl, ar dem ritaiya ar
dem ded, an fi dem pikni a get elp fram Suoshal
Sikyuuriti

- Moni we kom iin fram smadi we no liv a di ous

- Wan fren ar fambli we no liv a di ous an a gi di pikni
pakit moni

- Moni we kom iin fram eni ada plies

- Moni a kom iin regyula fi wan pikni fram wan puul a
penshan moni we no bilang tu govament, fram wan
penshan we bai, ar fram wan puul a moni we a kiip fi
di pikni

YU NO AFI TEL WI IF
YOU NO WAAHN TEL WI

Elp fram Govament/ Divuors Moni/
Moni fi Main Pikni

- Moni fi elp out sieka yu no av no
wok
- Pie we yu get sieka yu get inja pan
di jab
- Supplemental Security Income
(SSI)
- Elp-Out moni ina kyash we kom
fram di Stiet govament ar di
If yu wok wid di fuors dem we a
govament ina di ierya we yu liv
difen di konchri
- Divuors moni
- Di bier pie an di buonas dem we
- Moni we kom iin fi main pikni
yu get ina kyash (no put iin di pie
- Moni fi uu did de ina di fuors dem
we yu get wen yu a fait, an no bada we a difen di konchri an dem kom
with FSSA ar moni fi elp wid ous we out nou
yu rent out a schriit.)
- Moni fi elp out wen yu de pan
- Moni we yu kalek fi liv outsaid a di schraik
bies, moni fi fuud an moni fi kluoz.
- Pie fi wok we du, buonas we yu
get ina kyash
- Moni we yu bring iin fram wen yu
wok fa yuself laik ron faam ar
bizniz (di wat-lef afta di taks tek
out)

Elp fram Govament/ Divuors Moni/
Moni fi Main Pikni
- Suoshal Sikyuuriti (aal moni fi uu
ritaiya fram wok pan chrien an
chrienlain, an uu sofa fram blak
long siknis)
- Penshan ada dan govament
penshan, an moni we kom iin sieka
a yu inja ar yu badi no tuu iebl
- Moni we kom iin regyula fram wan
moni puul we smadi a luk afta fi yu,
an moni fram ded-lef
- Bai-penshan
- Moni we kom iin fram moni we yu
put fi wok fi yu
- Inchres pan moni we yu av ina di
bangk
- Moni fram rent we yu kalek
- Moni we kom iin regyula fram
outsaid a di ous fi pie piipl ina di ous

Di Pikni dem Bilang tu Wa Ries ar Gruup?

Di laa se wi fi aks yu bout yu pikni dem ries ar waeva gruup dem tingk se dem bilang tu. We yu kyan tel wi ya so impuortant kaaz it a elp wi mek shuor se wi a elp out evribadi ina di
komyuniti. Yu no afi ansa no kwestyan ina dis ya paat a d faam an if yu no ansa, it naa a chienj eni rait we yu pikni av fi get frii ar kot prais fuud a skuul.
We gruup yu bilang tu? Tik aaf wan.
Ispanik ar Latiino
Yu a no Ispanik ar Latiino
We ries yu bi? Yu kyan tik aaf wan ar muor dan wan baks
Amerikan Injan
Ieshan
Blak ar Afrikan Amerikan
Nietiv Awaiyan ar Ada Pasifik Ailanda
Wait
Enibadi we kyaahn diil wid regyula raitin pan faam an dem de sitn, an wi afi diil wid dem speshal so dem kyan
nuo bout dis ya pruogram, an dem waahn wi diil wid dem iina Briel, big print, tiep rikaadin, Amerikan Sain Langwij,
an dem de sitn, dem fi kantak di Stiet Afis ar di afis ina di ierya, wich paat dem sen iin di faam fi get elp. Eni smadi
we def, no ier tuu gud ar kyaahn taak tuu gud kyan yuuz di Federal Relay Service ((800) 877-8339) fi kantak wid
USDA. Pan tap a dat, wi kyan tel yu bout di pruogram no jos ina Ingglish bot ina ada langwij tu.
If yu fiil se yu no get chriit di siem wie laika evribadi els, an di chriitment yu get no fier, yu fi ful op di USDA
Pruogram Faam fi uu fiil se dem no get chriit iikwal (USDA Program Discrimination Complaint Form – AD-3027).
Yu kyan fain dis ya faam panlain a http://www.ascr.usda.gov/complaint_filing_cust.html ar yu kyan pik wan op
a eni USDA afis, ar yu kyan rait wan leta an tel wi evriting we di faam aks yu fa. If yu waahn wi sen yu wan faam,
fuon (866) 632-9992. Yu fi tek di faam we yu ful op an puos it fi go a di USDA a dis ya ajres a i :
Ajres if yu a sen leta: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410
Faks:
(202) 690-7442; or
iimiel:
program.intake@usda.gov.
Dis afis fi diil wid evribadi di siem wie an fi chriit evribadi iikwal

Di laa we niem di Richard B. Russell National School Lunch Act se wi afi aks yu di kwestyan dem we de pan dis
ya faam. Yu no boun fi ansa di kwestyan dem bot if yu no ansa dem, wi kyaahn se yes, yu pikni kyan get frii fuud
ar kot prais fuud. Di big smadi ina di yaad we a sain dis ya faam afi put iin di las fuor figa dem ina fi dem Soshal
Sikyuuriti Nomba. Dem laas fuor figa ya no afi rait dong if yu a ful out faam fi get elp fi wan pikni we di govament
rispans fa, ar if yu gi wan kies nomba fi di Supplemental Nutrition Assistance Program (SNAP), di Temporary
Assistance for Needy Families (TANF) Program, di Food Distribution Program on Indian Reservations (FDPIR) ar
yu yuuz wan neks wie ina FDPIR fi mek wi nuo uu di pikni bi. An yu no afi rait dong dem ya laas fuor figa if di big
smadi ina di yaad we a sain dis ya faam no av no Suoshal Sikyuuriti Nomba. Wi wi yuuz aal wi yu tel wi fi mek
op wi main se if yu pikni av di rait fi get frii fuud ar kot prais fuud. An wi wi yuuz we yu tel wi fi mek shuor se di
pruogram ron smuud an nobadi no get elp we no supuoz fi get elp. Wentaim wi fiil se wi shuda dwiit, wi wi mek
di edikieshan, elt an fuud pruogram dem si we yu tel wi. Dat wie, dem kyan chek fi si if yu av di rait fi get elp fram
fi dem pruogram. An wi maita shuo di aadita dem (we chek out if wi a spen di moni rait) an di puliis, fi dem chek
out if enibadi a brok di ruul dem.
Azkaadn tu di Federal laa we se evribadi fi get chriit iikwal, an azkaadn tu ruul dem we kachruol di U.S. Department
of Agriculture (USDA), aal a di sekshan dem, an aal a di afis dem we diil wid di USDA program dem, evribadi fi get
chriit iikwal, no mata we ries dem bi, kola dem bi, iej dem bi, an konchri dem kom fram.. An dat de laa se nobadi
fi get ponish sieka eniting dem maita did du fi difen iikwal raits ina eni ada pruogram ar bizniz di USDA a pie fa.

Yu No fi Ful
Out Ya So

A di Skuul fi Rait Ya So

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24 Monthly x 12

Eligibility:

How often?

Total Income

Weekly

Bi-Weekly

2x Month

Monthly

Household size

Free

Reduced

Denied

Categorical Eligibility
Determining Official’s Signature

Date

Confirming Official’s Signature

Date

Verifying Official’s Signature

Date