Household - 7 CFR 245

Attachment J38. Prototype Household Application for Free and Reduced Price School Meals Samoan
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

Faata’ita’iga Talosaga Aiga mo Mea’ai A’oga Maua Fua ma Faaitiitia Tau 2016-2017
Faatumu se talosaga se tasi mo le aiga ta’itasi. Faamolemole faaaoga se peni vaitusi (e le o se penitala).

LAASAGA 1

Lisi UMA Tagata o le Aiga, o pepe, tamaiti, ma tamaiti a’oga e oo atu ma aofia ai le vasega 12 (a mana’omia nisi laina mo igoa faaopoopo, faapipii mai se isi itulau)
Igoa Muamua o le Tamaitiiti

MI

Faai’u o le Tamaitiiti

Vasega

Tamitiiti A’oga?
Ioe
Leai

E agavaa mo mea’ai maua fua
tamaiti i le Tausiga Faatamafai
ma tamaiti e iai le faamatalaga
o le Leai ni Aiga, Fai Mai Fafo
poo le Sosola ese. Faitau le
Talosaga mo Mea’ai Maua Fua i
A’oga pe Faaitiitia Tau mo nisi
faamatalaga.

LAASAGA 2

Leai se Aiga, Fai
Tamaitiiti Tausi Mai Fafo, Sola
Faatamafai
Ese

Faasa’o uma pusa e talafeagai

Faamatalaina o le Tagata o le
Aiga: “Soo se isi o tou nonofo
ma faasoa tupemaua ma tupe
faaalu, tusa pe tou te le aiga.”

O auai se Tagata o le Aiga (aofia ai oe) i se tasi pe sili a’e o porokalama fesoasoani ia: SNAP, TANF, or FDPIR?
Afai e LEAI

LAASAGA 3

Numera Mataupu:

Afai IOE > Tusi se numera mataupu iinei ona alu lea i le LAASAGA 4
(Aua le faamae’aina le LAASAGA 3)

> Alu i le LAASAGA 3.

Tusi na’o se numera mataupu e tasi i le avanoa lenei.

Ripoti Tupemaua mo Tagata UMA o le Aiga (Sikipi le laasaga lenei pe afai na e tali ‘Ioe’ i le LAASAGA 2)
E faafia?

A. Tupemaua a Tamaiti

Tupemaua Tamaiti

E iai taimi e maua ai tupe a tamaiti o le aiga. Faamolemole ia tuu i ai i le vaega lenei le AOFA’I atoa o tupemaua a Tagata uma o le
Aiga ua lisi mai i le LAASAGA 1.

Vaiaso
Ta’itasi

Ta’ilua
Vaiaso

Faalua (2) Masina
i le Masina Ta’itasi

$

B. Tagata Matutua Uma o le Aiga (e aofia ai ma oe)
Pe ete le o mautinoa le
tupemaua e aofia iinei?

Lisi mai uma Tagata o le Aiga e le o lisiina i le LAASAGA 1 (aofia ai ma oe) tusa pe le o iai ni tupemaua. Mo Tagata ta’ito’atasi o le Aiga o loo lisi mai, afai e le o maua ni tupe, ripoti le aofa’i atoa (ae le’i tipiina lafoga) mo
alaga’oa ta’itasi i tālā atoatoa (leai ni sene). Afai latou te le maua se tupe mai se isi auala, tusi le ‘0’. Afai na e tusia le ‘0’ pe faaavanoa se tasi o vaega, ua e faamaonia (ta’utino) e leai se tupemaua e ripotia.

Susu’e le itulau ma taga’i i
le siata ua faaulutalaina
“Alaga’oa o Tupemaua” mo
nisi faamatalaga.

Igoa o Tagata Matutua o le Aiga (Muamua ma le Faai’u)

E faafia?
Tupemaua mai Galuega

Vaiaso
Ta’itasi

Ta’ilua
Vaiaso

E faafia?

Fesoasoani Lautele/Tausiga o
Fanau/Alimoni

Faalua (2) Masina
i le Masina Ta’itasi

Vaiaso
Ta’itasi

Ta’ilua
Vaiaso

Penisione/Ritaea/Nisi Uma
Tupemaua

Faalua (2) Masina
i le Masina Ta’itasi

$

$

$

O le siata o “Alaga’oa
Tupemaua mo Tamaiti” o le
a fesoasoani i le vaega o le
Tupemaua a Tamaiti.

$

$

$

O le siata o “Alaga’oa
Tupemaua mo Tagata
Matutua” o le a fesoasoani i
le vaega o Tagata Matutua
Uma o le Aiga.

$

$

$

$

$

$

$

$

$

Aofa’i Atoa Tagata o le Aiga
(Tamaiti ma Tagata Matutua)

LAASAGA 4

Fuainumera e Fa Mulimuli o le Numera Saogalemu
(SSN) o Tagata Faigaluega Autū o le Aiga poo se Isi
Tagata Matua o le Aiga

X

X

X

X

X

E faafia?
Vaiaso
Ta’itasi

Ta’ilua
Vaiaso

Faalua (2) Masina
i le Masina Ta’itasi

Faasa’o pe afai e leai se SSN

Faamatalaga fesoota’iga ma le saini tagata matua

“Ou te faamaonia (ta’utino) o faamatalaga uma i lenei talosaga e moni ma ua ripotia uma tupemaua. Ua ou malamalama o lenei faamatalaga ua avatu e fesoota’i ma le maua mai o tupe a le Feterale, ma e faamaonia e tagata o le a’oga (siaki) faamatalaga. Ua ou iloa afai ou te avatua ma le iloa ni
faamatalaga sese, e ono mamuli penefiti mea’ai a la’u fanau, ma e ono faasalaina a’u i lalo ifo o tulafono talafeagai a le Setete ma le Feterale.”

Tuatusi Auala (pe a iai)

Tusi lolomi le igoa o le tagata matua o loo sainia le pepa

Apt #

Aai

Saini a le tagata matua

Setete

Zip

Telefoni ma le Imeli i le Aso (le faamalosia)

Aso lenei

FAATONUGA

Alaga’oa o Tupemaua

Alaga’oa o Tupemaua a Tagata Matutua

Alaga’oa o Tupemaua a Tamaiti

Tupemaua mai Galuega

Faata’ita’iga

Alaga’oa o Tupemaua a Tamaiti

-E iai se galuega mautu pe faavaitaimi a se
tamaitiiti e maua ai se totogi

- Tupemaua mai galuega
- Saogalemu
- Peimeni o le le Atoatoa
- Penefiti o le o Soifua

- E tauaso pe le atoatoa se tamaitiiti ma o loo maua
penefiti Saogalemu
-E le atoatoa le malosi o se Matua, ritaea, po ua
maliu, ma o loo maua penefiti saogalemu a sona
alo

-Tupemaua mai se tagata i fafo atu o le aiga

- E masani ona ave e se tagata o le aiga poo
se uo tupe faaalu i se tamaitiiti

-Tupemaua mai se isi alaga’oa

- E maua se tupemaua masani e se
tamaitiiti mai se penisione tu ma’oti, anuiti,
poo se tupeteu

E LE FAAMALOSIA

- Totogi o galuega, tupe o pone
- Tupemaua atoa mai galuega
a le tagata lava ia (faato’aga
poo se pisinisi)
Afai o e i le Militeri U.S.:
- Totogi amata ma pone tupe
(AUA ne’i tuua i ai totogi o le
tau, FSSA poo alauni o fale i
tua)
- Alauni o fale i tua, mea’ai ma
lavalava

Penisione / Ritaea / Isi Uma
Tupemaua

Fesoasoani Lautele / Alimoni /
Tausiga o Fanau
- Penefiti le faigaluega

- Tupe Afaina o Tagata
Faigaluega
- Tupemaua Faaopoopo
Saogalemu (SSI)
- Fesoasoani tupe mai Setete
poo malo faalotoifale
- Peimeni alimony
- Peimeni tausiga o fanau
- Penefiti vetereni
- Penefiti o strike poo teva

-Saogalemu (aofia ai ritaea
auala ma penefiti tagata uli)
- Penisione Tu Ma’oti poo
penefiti o le le atoatoa
- Tupemaua masani mai
tupeteu poo esetete
- Anuiti
- Tupemaua i inivesi
- Tupe tului ua maua
- Tupemaua o le Mau Totogi
- Peimeni tupe masani mai
fafo atu o le aiga

Faasinogamaga i le Lanu ma Atunuu o Tamaiti

E faamalosia matou e fesili atu mo faamatalaga e uiga i le lanu ma le atunuu o lau fanau. E taua le faamatalaga lea ma e fesoasoani e faamaonia o loo matou tautua lelei i le nuu. O lou tali i
lenei vaega e le faamalosia ma e le aafia ai le agavaa o lau fanau mo mea’ai maua fua pe faaitiitia tau.

Atunuu (faasa’o se tasi):

Mesiko pe Latino

Lanu (faasa’o se tasi pe sili atu):
Tagata Pa’epa’e

E le o se Mesiko pe Latino

Initia Amerika pe Tagatanuu Alaska

Asia

Tagata Uli poo Aferika Amerika

Tagatanuu Hawaii poo Nisi Tagata Pasefika

O tagata e le atoatoa e mana’omia nisi ala o fesoota’iga poo faamatalaga o porokalama (e pei o Braille, tusi mata
tetele, ripine faaleo, Gagana Faagugu a Amerika, ma nisi), e tatau ona faafesoota’i le Ofisa (Setete pe lotoifale) na
talosaga ai mo penefiti. O tagata e le lagona se mea, pe faigata ona lagona, pe faaletonu le tautala e mafai ona
faafesoota’i le USDA e ala i le Tautua Faaoo a le Feterale i le (800) 877-8339. E faaopoopo i ai, o faamatalaga o le
porokalama e mafai ona maua i nisi gagana ese mai le Igilisi.
A fia faila se tagi le malie tau Gagana i le porokalama, faatumu le Pepa USDA Tagi Le Malie Faailoga Tagata i le
Porokalama (AD-3027) e maua i le initaneti i le http://www.ascr.usda.gov/complaint_filing_cust.html, i soo se
ofisa o le USDA, poo le tusi o se tusi faatuatusi i le USDA ma ave ai i le tusi faamatalaga uma o loo talosagaina i
le pepa. A fia talosaga mo se kopi o le pepa tagi le malie, valaau (866) 632-9992. Faaoo le pepa ua faatumu poo
le tusi i le USDA i le:

E faamalosia e le Richard B. Russell National School Lunch Act faamatalaga i lenei talosaga. E le faamalosia oe e
aumai, ae afai e te le aumaia, e le mafai ona talia lau talosaga mo mea’ai maua fua pe faaitiitia tau a lau tamaitiiti.
E tatau ona iai fuainumera mulimuli e fa o le numera Saogalemu o le tagata matua o loo sainia le talosaga. E le
faamalosia fuainumera mulimuli ia e fa o le saogalemu pe afai o loo e talosaga mo se tamaitiiti tausi faatamafai
pe na lisi mai se numera mataupu Porokalama Fesoasoani Taumafa Nutereni (SNAP), Porokalama Fesoasoani
le Tumau mo Aiga Vaivai (TANF), poo se Porokalama Tufa Mea’ai a Initia (FDPIR) poo se isi numera faailoa FDPIR
mo lau tamaitiiti pe sa e faailoa o le tagata matua o loo sainia le talosaga e leai sona numera saogalemu. Matou
te faaaogaina lau faamatalaga e iloa ai pe agavaa lou alo mo mea’ai maua fua pe faaitiitia tau, ma galuega a le
pule’aga ma le faamalosiga o porokalama o ‘aiga o le aoauli ma taeao. E MAFAI ona matou faasoaina au faamatalaga
o le agavaa aga’i i a’oa’oga, soifua maloloina, ma porokalama taumafa nutereni e fesoasoani ai e fuafua, faatupe,
pe faamautu penefiti o a latou porokalama, su’egatusi mo iloiloga o porokalama, ma ofisa faamalosi o tulafono e
fesoasoani ai ia latou taga’i toto’a i le solia o tulafono a le porokalama.

Meli:

U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW

E tusa ai ma tulafono o aia tatau a le Feterale ma aiaiga ma tulafono o aia tatau a le Matagaluega o Faato’aga
(USDA), e faasa le USDA, ona Sui, ofisa, ma tagata faigaluega, ma ona lālā o loo pulega pe faafoeina porokalama
USDA mai le faailoga tagata i lanu, atunuu, malo, tane/fafine, le atoatoa, tausaga, poo le taui pe faasala se isi
ona sa auai muamua i ni faatinoga o aia tatau i soo se porokalama poo faatinoga e faafoe pe faatupe e le USDA.

Washington, D.C. 20250-9410
Fax:

(202) 690-7442; poo lee

Email:

program.intake@usda.gov.

O lenei ofisa o se tautua e maua ai aiā tutusa.

Aua le faatumuina

Faaaoga na’o le A’oga

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