PERRY CENTRAL COMMUNITY SCHOOL CORPORATION18677 Old State Road 37Leopold, Indiana 47551

Central Office (812) 843-5576Fax (812) 843-4746www.pccs.k12.in.us

High School Office: 812-843-5121 High School Fax: 812-843-4198

Elementary Office: 812-843-5122Elementary Fax: 812-843-5242

2018-2019 NewsletterBack to School Cookout

2018-2019 School CalendarSchool Supply List

7th Grade OrientationElementary News

Preschool InformationBook Rental

Cafeteria NewsAugust Menus

Health Office Info & FormsTitle I Right to Know

Free/Reduced Meal Application

School Begins Tuesday, August 7, 2018 for all K-12 students

Preschool will begin onWednesday, August 8, 2018 for Wednesday/Thursday students

Monday, August 13 for Monday/Tuesday students

Perry Central Family Outreach

August 6 - First Teacher DayS M T W T F S S M T W T F S August 7 - First Student Day

1 2 3 4 1 August 8 - First Day W/Th Preschool5 6 7 8 9 10 11 2 NS 4 5 6 7 8 August 13 - First Day M/T Preschool

12 13 14 15 16 17 18 9 10 11 12 13 14 15 September 3 - Labor Day (NS)19 20 21 22 23 24 25 16 17 18 19 20 21 22

26 27 28 29 30 31 23 24 25 26 27 28 29

30

October 5 - End of Quarter 1S M T W T F S S M T W T F S October 15-19 - Fall Break (NS)

1 2 3 4 5 6 1 2 3 November 21-23 - Thanksgiving7 8 9 10 11 12 13 4 5 6 7 8 9 10 Break (NS)

14 NS NS NS NS NS 20 11 12 13 14 15 16 17

21 22 23 24 25 26 27 18 19 20 NS NS NS 24

28 29 30 31 25 26 27 28 29 30

December 21 - End of Quarter 2S M T W T F S S M T W T F S Dec 24-Jan 1 - Winter Break (NS)

1 NS MU 3 4 5 January 2 - Winter Break (NS/MU)2 3 4 5 6 7 8 6 7 8 9 10 11 12 January 21 - MLK Day (NS/MU)9 10 11 12 13 14 15 13 14 15 16 17 18 19

16 17 18 19 20 21 22 20 MU 22 23 24 25 26

23 NS NS NS NS NS 29 27 28 29 30 31

30 NS

February 18 - President's Day (NS/MU)S M T W T F S S M T W T F S March 8 - End of Quarter 3

1 2 1 2 March 18-22 - Spring Break (NS)3 4 5 6 7 8 9 3 4 5 6 7 8 9

10 11 12 13 14 15 16 10 11 12 13 14 15 16

17 MU 19 20 21 22 23 17 NS NS NS NS NS 23

24 25 26 27 28 24 25 26 27 28 29 30

31

April 19 - Good Friday (NS)S M T W T F S S M T W T F S April 22 - Easter Monday (NS/MU)

1 2 3 4 5 6 1 2 3 4 May 21 - Last Day Students7 8 9 10 11 12 13 5 6 7 8 9 10 11 May 22 - Last Day Teachers

14 15 16 17 18 NS 20 12 13 14 15 16 17 18 May 26 - Tentative Grad. Date21 MU 23 24 25 26 27 19 20 21 MU MU MU 25 May 27 - Memorial Day (NS)28 29 30 26 NS MU MU MU MU

Make Up Days: January 2, January 21, February 18, April 22, May 22, May 23, May 24 NS = No SchoolMay 28, May 29, May 30, May 31 Yellow Highlight MU = Make-Up Day

Blue Highlight = End of QuarterOrange Highlight = HS Mid Term Dates

Perry Central Commodores - www.pccs.k12.in.us

FEBRUARY MARCH

APRIL MAY

Perry Central Schools

JANUARY

2018-2019 Calendar

AUGUST SEPTEMBER

OCTOBER NOVEMBER

DECEMBER

PRESCHOOL GRADE FOUR1 Tri-fold Mat for naps Backpack with Laptop Compartment1 Standard Size Backpack w/room for folder 2 Large Boxes of Tissues1 Large Box of Tissues Colored Pencils OR Box of Crayons1 Box Dry Erase Markers Pencil Box or PouchBoys: 1 Box Gallon Size Heavy-Duty Slider Ziploc Bags 1 Dozen PencilsGirls: 1 Box Quart Size Heavy-Duty Slider Ziploc Bags 3 Pkgs. Expo Brand Dry Erase Markers

ScissorsKINDERGARTEN Earbuds or Headphones (Durable)Backpack (no wheels) Boys: Quart size Ziploc Bags2 Large Boxes of Tissues Girls: 1 Bottle of Germ-X4 Glue Sticks1 Dozen Pencils GRADE FIVE1 Bottle of Germ-X Backpack with Laptop Compartment1 Pair of Headphones (No Earbuds) Headphones or EarbudsBoys: 2 pkgs. Black Expo Dry Erase Markers 2 Boxes of #2 PencilsBoys: 1 Box Quart Size Heavy-Duty Slider Ziploc Bags Colored PencilsGirls: 2 pkgs. Color Expo Dry Erase Markers ScissorsGirls: 1 Box Gallon Size Heavy-Duty Slider Ziploc Bags 2 Boxes of Tissues

1 Glue StickGRADE ONE Art Box Backpack (no wheels) 2 pkgs. Expo Brand Dry Erase Markers2 Large Boxes of Tissues Highlighters8 Glue Sticks Boys: Disinfectant WipesScissors (Fiskars round edge) Girls: 12 oz. Bottle of Germ-X12 oz. Bottle of Germ-XArt Box (No Pouches) GRADE SIXBoys: Crayola Washable Markers Backpack with Laptop Compartment Boys: Quart size Ziploc Bags 2 dozen #2 Pencils Girls: Colored Pencils Colored PencilsGirls: Gallon size Ziploc Bags 1 - 4 pack of Dry Erase MarkersNO SMALL PENCIL SHARPENERS OR NOTEBOOKS Supply Box/Bag

Glue StickGRADE TWO 2 Large Boxes of TissuesScissors Headphones or Earbuds2 Glue Sticks 1-Lg. Spiral Notebook Crayons 1" Binder2 Large Boxes of Tissues Scissors2 Dozen #2 Pencils (no large pencils) Boys: Disinfectant Wipes2 Pink Erasers Girls: 12 oz. Bottle of Germ-XSmall Box for Supplies2 pkgs. Dry Erase Markers (Expo Brand Only) GRADES 7 - 1212 oz. Bottle of Germ-X Bring basic items the first day, such as paper,Earbuds or Headphones pencils and/or pens. Individual teachers may

suggest other items as needed.GRADE THREE1 Dozen #2 Pencils + 2 Dozen for Pencil BankScissors2 Glue Sticks2 Large Boxes of TissuesSmall Box/Pouch for Supplies (no larger than 8"x6")1 Pair of Headphones (No Earbuds)2 Highlighters2 pkgs. Dry Erase Markers (Expo Brand Only)24 Count Crayola CrayonsBoys: Large Container of Disinfectant WipesGirls: 12 oz. Bottle of Germ-X

Perry Central Elementary School ~ 2018-2019 School Supply List

Families that qualify for Free/Reduced Lunches can receive school supply assistance through Perry Central's school supply bank.

7TH GRADE ORIENTATIONAll incoming 7th graders

along with their parents are invited to attend 7th grade

Orientation

WednesdayAugust 1, 2018

Students will learn about new graduation requirements, Perry Central Career Pathways, 21st Century Scholarship

information along with getting a copy of their 7th grade schedule. Students will also have the opportunity to tour the junior/senior high school building,

meet teachers and practice opening their lockers.

A light supper will begin at 5:30 p.m. with the program starting at 6:00 p.m. in the Cafetorium.

If you have any questions or for more information please email Mrs. French jfrench@pccs.k12.in.us

The following are a few reminders we would like to share with parents and students concerning the operation of the school day.

ALL ELEMENTARY STUDENTS MUST WEAR CLOSED-TOED SHOES.

From time to time we have students who arrive at school before the start of the regular school day. We have worked with parents and students in the past whenever the need for early drop off has arisen and we will continue to do so this year. All students who arrive between 7:00- 7:45 AM are expected to report to the dome.

All students, upon entering the opening day of school, must have immunizations complete and a birth certificate on file in the elementary office.

Students have toys, cell phones, and other personal items that they wish to bring to school. We are asking that parents monitor what students are placing in pockets and backpacks. We cannot be responsible for items that students may bring to school. The best prevention for loss and/or theft is to leave the item at home. Cell phones must be off and out of sight during the school day.

Parents play a key role in the education of their children. By working together we can ensure that all children reach their potential. As questions or problems arise, do not hesitate to ask for a parent-teacher conference. Our goal is to provide a safe, fun, and enriching environment for all students. We know that communication between home and school is essential to the learning process and growth of children. Lights-On After School Program: Dixie Dickerson serves as the director for our after school program that is available every school day until 6:00 PM, except on days when school is dismissed due to inclement weather. Lights On is available to all students enrolled in the elementary, grades preschool to sixth, and is free of charge. Students will be provided a snack, can participate in a variety of workshops that range from fitness to the arts. There will be a schedule on the Lights On door. Tutoring is also available. The program is always in need of volunteers, so please contact Dixie Dickerson if you want to get involved. Stop by the Lights On table during the Back to School Picnic for more information. Look for information early in the school year about evening transportation that will leave Perry Central at 5:30 Monday – Thursday with drop off points within our school district.

PRESCHOOL INFORMATIONPerry Central is proud to provide a preschool for our children and is continually

striving to enhance the program.

Preschool will begin onWednesday, August 8, 2018 for Wednesday/Thursday students

Monday, August 13, 2018 for Monday/Tuesday students

EnrollmentPreschool enrollment and orientation was held in April. Children who are four by August 1st are eligible to attend. There are two class sessions: Monday/Tuesday and Wednesday/Thursday. Class assignments will be available at the Back to School Cookout. All efforts will be made to honor family requests for specific days of class. If enrollment is full, students will be placed on a waiting list. All efforts will be made to enroll interested students, but because this is not a tax-funded program we cannot guarantee enrollment.

Preschool Participation FeesThe fee schedule for preschool is as follows: Daily rate: $10/day Reduced rate: $6/day for students qualifying for free or reduced lunchPreschool fees are billed at the end of each school week, based on the number of days your child attended and the fees are due the following week. Please remember that Perry Central’s Preschool is a self-supporting program which means that your child’s preschool fees pay for all expenses incurred with your child’s educational experience at Perry Central’s Preschool. Timely payments must be made to allow your child to remain enrolled in this self-supporting preschool program.

Preschool Lunch & Snack Fees• The snack and supply fee is $25.00 for the school year.• Lunch payments must be paid by a separate check from snack & supply fees.

Miscellaneous Information• Snack & Supply Fees and Lunch payments may be paid during the scheduled times for book rental sales.• Student nametags may be picked up at the Back to School Cookout. • Please refer to the School Supply List for a list of supplies your child will need for Preschool. Items need to be received on or before the first day of preschool. We encourage you to bring them with you to the Back to School Cookout. All other supplies will be furnished. • Bus drivers will contact families for pick-up times. Please call school if you have questions about your bus route or any other questions.

BOOK RENTAL

Payment for books or arrangements to pay must be made before the first day of school. All past due accounts must be paid in full before arrangements can be made to pay your 2018-2019 book rental.

***********************************

Book rental will be collected in the HIGH SCHOOL COMMONS AREA at the following times. If you cannot come during these times, we suggest you send your check or money order to the school by mail or pay online.

Thursday, August 2 ---------------- 8:00 AM to 7:00 PM Friday, August 3 ---------------- 8:00 AM to 2:00 PM

Due to a ruling by the State Board of Accounts, all checks or money orders must be written for the exact amount of book rental or lunches. Payroll checks cannot be cashed and used for payment.

***********************************

2018 - 2019 Book Rental Prices

Kindergarten ----------$80.00 Grade Four ----------$88.00Grade One -------------$53.00 Grade Five -----------$90.00Grade Two -------------$95.00 Grade Six -------------$99.00Grade Three -----------$91.00

CAFETERIA NEWSThe Perry Central Café offers a variety of healthy options for students each school day.

CAFETERIA CHARGING POLICY

The State Board of Accounts will not allow students to charge for school meals. Meal accounts for students need to have a positive balance at all times. (Think of them as a debit card, not a credit card.) Federal guidelines and our policy allow for a maximum of a $5 negative balance to allow for timing issues. Please do not think we are being insensitive, but state and federal guidelines have brought us to this point. At the same time, we want to make sure that every child has something healthy to eat each day.

If your child has a debt, please pay the account off in full or send his/her lunch to school each day. We will not deny students food, so we will have an option available for students who have a negative balance. (Most likely this will be a peanut butter/jelly sandwich.)

(Continued on next page)

LUNCH PAYMENTSAll students in grades PK-12 will need to have money in their lunch account prior to the first day of school. For your convenience, lunch payments can be paid online via Skyward, or a check can be mailed or brought to school during book rental. However, lunch money cannot be included on the same check as book rental.

If you cannot pay for lunches before the first day of school, we suggest that you send the appropriate amount of money with your child for his or her meals on the first day.

Skyward Log-In: Skyward is our student information system, which provides “one-stop shopping” for parents, students, and staff. Parents can check grades, discipline records, and attendance; communicate with teachers; make credit card payments; and much more. There is a quick link to Skyward on the homepage of our website. If you need to update your email address or if you need additional assistance, please call our office at 812-843-5576 or email techsupport@pccommodores.org.

No Change at Lunch LineBeginning in the 2018-2019 school year there will be no change given in the lunch line. This is to speed up the line and to avoid errors. Students can have exact change for à la carte purchases or the overage will be applied to their lunch account.

CAFETERIA NEWS

LUNCH OPTIONS

Lunch is offered daily in the cafeteria between 10:45 AM-1:30 PM. • Pre-School – 2nd grade: Type A Lunch Tray • 3rd – 4th grade: Type A Lunch Tray or Salad Tray • 5th – 12th grade: Type A Lunch Tray or Sub Tray or Salad Tray or Soup & Sandwich Tray o Healthy Chips will be available for purchase for $1.00 for 5th-12th graders. o 5th/6th grade students must pay for chip purchases as they go through the lunch line. o 7th-12th grade may charge chips to their lunch account as long as they have money in their lunch account.

FREE/REDUCED LUNCH APPLICATIONS Our goal is to help any qualifying family utilize federally subsidized meals for their children. If you think you may qualify, we hope you will apply. To make the process more convenient, we are moving to an on-line application process. Paper applications will still be accepted and can be found on our website, or we will send you one if you call 812-843-5576.

To apply on-line: • From the Perry Central website – www.pccs.k12.in.us • Click on the Skyward link and log-in. • Click on the Food Service tab on the left side of the page. • Click on the Application button on the top right of the page. • From the Application page, click “Add Application”. • Read and follow the directions using the NEXT button to go through the application packet.

CAFETERIA FEES

• Lunch for all students Pre-School - 12th grade will be $2.55. • The cost for breakfast for students is $1.25. • Reduced price is 40¢ for lunch and 30¢ for breakfast.

BREAKFASTBreakfast is offered daily. Students that qualify for Free/Reduced are eligible for a breakfast tray. Elementary students in grades Pre-School-6th will be served breakfast from 7:45 AM-8:30AM in the cafeteria. Jr./Sr. High students in grades 7-12 may purchase breakfast in the High School Commons Area from 7:30 AM-8:00 AM.

Understanding the Lunch Line: A Parent’s Guide

Each day, your child is offered a lunch containing the following:

Meat or Meat Alternate, Grain,

Fruit, Vegetable

and of course, Milk!

While the most nutritious lunch contains all of these options, we understand that sometimes our students do not like some of the

items we serve. To make our student customers happy, we like to give them the option to decline

items they do not want to eat.

Out of the 5 food groups your student is offered, he must choose at least 3 food groups for his meal. One of the food groups must be a fruit or vegetable. Some of the menu choices may count as two food groups

such as pizza, nachos, cheeseburger, or chef salad!

Here’s an example menu: Cheeseburger on a Bun

1/2 cup Carrots 1/2 cup French Fries

1/2 cup Peaches 8oz of Milk

So, your child could choose: Cheeseburger on a Bun and Fries

Carrots, Peaches and Milk

Cheeseburger on Bun, Peaches and Milk

Of course they can take other combinations or all 5 food groups!

The choice is up to them!

If your child comes home and says she didn’t get enough to eat at lunch, ask if she is taking all of her fruit and vegetable choices!

Don’t forget about breakfast! Join us each morning, breakfast is a great way

to kick off your child’s day!

Breakfast choices are a little different. Students must take at least 3 of the

offered items at breakfast, one must be a fruit or vegetable.

This institution is an equal opportunity provider.

Monday Sausage & Egg Biscuit Sandwich

Tuesday Blueberry Muffin with Sausage

Wednesday French Toast Sticks

Thursday Breakfast Pizza

Friday Biscuit & Gravy with Sausage

This institution is an equal opportunity provider.

Breakfast is offered daily in the Cafeteria from 7:45-8:30 AM.

Elementary (Preschool - 6th Grade) Menu

A choice of cereal is offered each day.Milk, juice, and fruit are served daily with breakfast.

The menu below will repeat weekly.

Monday Sausage & Egg Biscuit Sandwich

Tuesday Blueberry Muffin with Sausage

Wednesday French Toast Sticks with Sausage

Thursday Breakfast Pizza

Friday Biscuit & Gravy with Sausage

A choice of cereal is offered each day.

This institution is an equal opportunity provider.

Breakfast is offered daily in the HS Commons Area from 7:30-8:00 AM.

High School (Grades 7-12) Menu

Parfaits offered each day.

Milk, juice, and fruit are served daily with breakfast.

The menu below will repeat weekly.

6

Corn Dog Baked Beans

Peaches

7

PizzaburgerCorn

Mixed FruitChocolate Chip Cookie

8

BurritoCooked Broccoli

Pineapple

9

PizzaFrench FriesApplesauce

10

Taco SaladCornPears

13

Hamburger on BunBaked Potato Half

Cole SlawPeaches

14

Chicken & DumplingsGreen Beans

RollApplesauce

15

Chicken Patty on BunBaked BeansMixed Fruit

16

Bosco SticksFrench Fries

Marinara SaucePineapple

17

SpaghettiCorn

BreadstickPears

20

BBQ Rib Patty on BunCooked Carrots

Peaches

21

Salisbury SteakMashed Potatoes

Gravy / RollGreen BeansApplesauce

22

Pork Patty on Bun Mixed Vegetables

Pineapple

23

Mexican BowlPeas

Mixed FruitChocolate Pudding

24

County Fried Steak Sand.Mashed Potatoes

GravyGreen Beans

Pears

27

Fish NuggetsPeas

Pasta SaladPeaches

28

LasagnaCorn

Garlic BiscuitMixed Fruit

Chocolate Chip Cookie

29

Chicken Noodle SoupGrilled Cheese or

Peanut Butter Sand.Applesauce

30

Pizza French FriesPineapple

31

August Lunch Menu

Birthday treat for all K-6th graders

Peanut butter & jelly sandwiches are offered each day.Milk and fruit are served with lunch entrée.

Carrots, broccoli, celery sticks, and cauliflower are offered daily.Fresh fruits offered daily.

This institution is an equal opportunity provider.

Grades 3 & 4 will have an additional choice of the salad bar DAILY.Grades 5 - 12 will have an additional choice of a sub entrée, soup & sandwich entrée, or the salad bar DAILY.

Monday Tuesday Wednesday Thursday Friday

Health Office Information and NoticesSchool Nurse: Susan Huber | 812-843-5121, extension 135 | shuber@pccs.k12.in.us

2018-2019 School Year School Entry Immunization RequirementsBelow are the number of doses and each vaccine required for school entry. The school nurse asks that you begin making arrangements to have your child immunized at your earliest convenience. This can be arranged with Perry County Hospital at the shot clinic for students with insurance. Uninsured students and students with Medicaid may continue to go to the Perry County health department.

School Immunization Reporting: Perry Central will be participating in the CHIRP system. Parents will be asked to give their consent electronically in Skyward upon enrollment. This will be a one time acknowledgment.

3 to 5 years old

3 Hep B (Hepatitis B)4 DTaP (Diphtheria, Tetanus & Pertussis)3 Polio (Inactivated Polio)1 MMR (Measles, Mumps & Rubella)1 Varicella

K-3rd grade3 Hep B 2 MMR5 DTaP 2 Varicella4 Polio 2 Hep A (Hepatitis A)

Grades 4 to 53 Hep B 2 MMR5 DTaP 2 Varicella4 Polio 2 Hep A*

Grades 6 to 113 Hep B 2 MMR5 DTaP 2 Varicella4 Polio 1 Tdap (Tetanus & Pertussis)2 Hep A* 1 MCV4 (Meningococcal)

Grade 12

3 Hep B 2 MMR5 DTaP 2 Varicella4 Polio 1 Tdap (Tetanus & Pertussis)2 Hep A* 2 MCV4 (Meningococcal) 2 MenB (Meningococcal B)**

Hep B The minimum age for the 3rd dose of Hepatitis B is 24 weeks of age.

DTaP Four doses of DTaP/DTP/DT are acceptable if the 4th dose was administered on or after child’s 4th birthday.

Polio Three doses of Polio are acceptable for all grade levels if the third dose was given on or after the child’s 4th birthday and at least 6 months after the previous dose with only one type of vaccine used (all OPV or all IPV.) For students in grades kindergarten through 7th grade, the final dose must be administered on or after the 4th birthday, and be administered at least 6 months after the previous dose.

Varicella Physician documentation of disease history, including month and year, is proof of immunity for children entering preschool through 9th grade. Parental report of disease history is acceptable for grades 10-12.

MCV4 Individuals who receive dose 1 after their 16th birthday only need 1 dose of MCV4.

Hep A The minimum interval between 1st and 2nd dose is 6 calendar months. K-3 is required.*For grades 4-12, two doses of Hep A are recommended.

MenB **Two doses of Meningococcal Serogroup B vaccine are recommended for Grade 12.

Annual Permission Form To Administer Specific Medications

I request that school personnel administer the medication(s) and its dosage that is checked below to my child while he/she is in attendance at school. Please note any special instructions below. I also request that any prescription medication sent to school be given in accordance with the written instructions from the physician.

STUDENT’S NAME____________________

____Tylenol/Acetaminophen (Non-aspirin) tabs as needed

_____500mg (1tab) _____1000mg (2tab) _____other ________________

____Ibuprofen (Advil/Motrin) tabs

_____200mg _____400mg _____other_________________

Any other Medication and Dosage: _______________________________________________________________________________________________________________

Parent/Guardian__________________________________Date_____________

All medication must be in original containers or they cannot be administered by school personnel.

August 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

September 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

October 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

November 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

January 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

February 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

March 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

April 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

May 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Administering personnel signature/initials ________________________ ________________________ Day initialed when medication given

Perry Central Community School Corporation | Leopold, Indiana 47551

Medication: If your child needs to have medication administered at school, please complete the permission form. This can also be used for permission to administer Tylenol, Advil or other over the counter medications as needed. School personnel cannot administer medication un-less it is in its original container and permission is given by parents. If you think your child will require Tylenol or Ibuprofen at school, a bottle needs to be provided. All medications will be destroyed at end of school year if not picked up from nurse’s office by the parent or student in grades 9-12.

PERRY CENTRAL WILL NOT KEEP BULK SUPPLY OF TYLENOL OR IBUPROFEN THIS SCHOOL YEAR.

Perry Central Community School Corporation 18677 Old State Road 37

Leopold, IN 47551 (812) 843-5576

FAX (812) 843-4746 Mary Roberson, Superintendent

July 1, 2018 Dear Parents and Guardians: In accordance with the Elementary and Secondary Education Act, Section 1111(h)(6) PARENTS' RIGHT TO KNOW, this is a notification from Perry Central Community School Corporation to every parent of a student in a Title I school that you have the right to request and receive information in a timely manner regarding the professional qualifications of your student's classroom teachers. This information regarding the professional qualifications of your student's classroom teachers shall include the following: • If the teacher has met state qualification and licensing criteria for the grade level and subject areas taught; • If the teacher is teaching under emergency or temporary status in which Indiana qualifications and licensing criteria are waived; • The teachers baccalaureate degree major, graduate certification, and field of discipline; and • Whether the student is provided services by paraprofessionals, and if so, their qualifications If at any time your student has been taught for 4 or more consecutive weeks by a teacher that is not highly qualified, you will be notified by the school of this information. If you have questions or concerns, please feel free to contact Jennifer Mitchell, Perry Central Elementary Principal at 812-843-5122, or me at 812-843-5576. Sincerely,

Mary Roberson Superintendent

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char

t.

2.

HOW

DO

I KN

OW

IF M

Y CH

ILDR

EN Q

UALI

FY A

S HO

MEL

ESS,

MIG

RAN

T, O

R RU

NAW

AY?

Do th

e m

embe

rs o

f you

r hou

seho

ld la

ck a

per

man

ent a

ddre

ss?

Are

you

stay

ing

toge

ther

in a

shel

ter,

hote

l, or

oth

er te

mpo

rary

hou

sing

arra

ngem

ent?

Doe

s you

r fam

ily re

loca

te o

n a

seas

onal

bas

is? A

re a

ny ch

ildre

n liv

ing

with

you

who

hav

e ch

osen

to

leav

e th

eir p

rior f

amily

or h

ouse

hold

? If

you

belie

ve ch

ildre

n in

you

r hou

seho

ld m

eet t

hese

des

crip

tions

and

hav

en’t

been

told

you

r chi

ldre

n w

ill g

et fr

ee m

eals,

ple

ase

call

or e

-mai

l Tar

a Bi

shop

, Ass

istan

t Sup

erin

tend

ent,

at 8

12-8

43-5

576

or tb

ishop

@pc

cs.k

12.in

.us.

3.

DO

I NE

ED T

O F

ILL O

UT

AN A

PPLI

CATI

ON

FOR

EACH

CHI

LD?

No.

Use

one

Fre

e an

d Re

duce

d Pr

ice S

choo

l Mea

ls Ap

plica

tion

for a

ll st

uden

ts in

you

r hou

seho

ld. W

e ca

nnot

ap

prov

e an

app

licat

ion

that

is n

ot co

mpl

ete,

so b

e su

re to

fill

out a

ll re

quire

d in

form

atio

n. R

etur

n th

e co

mpl

eted

app

licat

ion

to: P

erry

Cen

tral

Com

mun

ity S

choo

l Co

rpor

atio

n, A

tten

tion:

Lor

a Hu

bert

, ECA

Tre

asur

er, 1

8677

Old

Sta

te R

oad

37, L

eopo

ld, I

N 4

7551

. 4.

SH

OUL

D I F

ILL O

UT A

N AP

PLIC

ATIO

N IF

I RE

CEIV

ED A

LETT

ER T

HIS

SCHO

OL Y

EAR

SAYI

NG

MY

CHIL

DREN

ARE

ALR

EADY

APP

ROVE

D FO

R FR

EE M

EALS

? N

o, b

ut p

leas

e re

ad

the

lett

er y

ou g

ot ca

refu

lly a

nd fo

llow

the

inst

ruct

ions

. If a

ny ch

ildre

n in

you

r hou

seho

ld w

ere

miss

ing

from

you

r elig

ibili

ty n

otifi

catio

n, co

ntac

t Lor

a Hu

bert

, ECA

Tr

easu

rer,

1867

7 O

ld S

tate

Roa

d 37

, Leo

pold

, IN

475

51, o

r by

phon

e at

(812

) 843

-557

6 or

by

emai

l at l

hube

rt@

pccs

.k12

.in.u

s im

med

iate

ly.

5.

CAN

I APP

LY O

NLIN

E? Y

es! Y

ou a

re e

ncou

rage

d to

com

plet

e an

onl

ine

appl

icatio

n in

stea

d of

a p

aper

app

licat

ion

if yo

u ar

e ab

le. T

he o

nlin

e ap

plica

tion

has t

he sa

me

requ

irem

ents

and

will

ask

you

for t

he sa

me

info

rmat

ion

as th

e pa

per a

pplic

atio

n. V

isit w

ww

.pcc

s.k1

2.in

.us t

o be

gin

or to

lear

n m

ore

abou

t the

onl

ine

appl

icatio

n pr

oces

s. Co

ntac

t Lor

a Hu

bert

, ECA

Tre

asur

er, 1

8677

Old

Sta

te R

oad

37, L

eopo

ld, I

N 4

7551

, 812

-843

-557

6, o

r by

emai

l lhu

bert

@pc

cs.k

12.in

.us,

if yo

u ha

ve a

ny q

uest

ions

abo

ut th

e on

line

appl

icatio

n.

6.

MY

CHIL

D’S

APPL

ICAT

ION

WAS

APP

ROVE

D LA

ST Y

EAR.

DO

I NE

ED T

O F

ILL O

UT A

NEW

ON

E? Y

es. Y

our c

hild

’s ap

plica

tion

is on

ly g

ood

for t

hat s

choo

l yea

r and

for t

he fi

rst

few

day

s of t

his s

choo

l yea

r thr

ough

Tue

sday

, Sep

tem

ber 1

8, 2

018.

You

mus

t sen

d in

a n

ew a

pplic

atio

n un

less

the

scho

ol to

ld y

ou th

at y

our c

hild

is e

ligib

le fo

r the

new

FEDE

RAL E

LIGI

BILI

TY IN

COM

E CH

ART

For S

choo

l Yea

r 201

8-19

Ho

useh

old

size

Year

ly

Mon

thly

W

eekl

y 1

22,4

59

1,87

2 43

2 2

30,4

51

2,53

8 58

6 3

38,4

43

3,20

4 74

0 4

46,4

35

3,87

0 89

3 5

54,4

27

4,53

6 1,

047

6 62

,419

5,

202

1,20

1 7

70,4

11

5,86

8 1,

355

8 78

,403

6,

534

1,50

8 Ea

ch a

dditi

onal

+7

,992

+6

66

+154

Pare

nt Le

tter

/Inst

ruct

ions

- PY

201

9

scho

ol y

ear.

If yo

u do

not

send

in a

new

app

licat

ion

that

is a

ppro

ved

by th

e sc

hool

or y

ou h

ave

not b

een

notif

ied

that

you

r chi

ld is

elig

ible

for f

ree

mea

ls, y

our c

hild

will

be

char

ged

the

full

price

of m

eals.

7.

I G

ET W

IC.

CAN

MY

CHIL

DREN

GET

FRE

E M

EALS

? C

hild

ren

in h

ouse

hold

s par

ticip

atin

g in

WIC

may

be

elig

ible

for f

ree

or re

duce

d pr

ice m

eals.

Ple

ase

send

in a

n ap

plica

tion.

8.

W

ILL T

HE IN

FORM

ATIO

N I

GIVE

BE

CHEC

KED?

Yes

. We

may

also

ask

you

to se

nd w

ritte

n pr

oof o

f the

hou

seho

ld in

com

e yo

u re

port

. 9.

IF

I DO

N’T

QUA

LIFY

NO

W, M

AY I

APPL

Y LA

TER?

Yes

, you

may

app

ly a

t any

tim

e du

ring

the

scho

ol y

ear.

For

exa

mpl

e, ch

ildre

n w

ith a

par

ent o

r gua

rdia

n w

ho b

ecom

es

unem

ploy

ed m

ay b

ecom

e el

igib

le fo

r fre

e an

d re

duce

d pr

ice

mea

ls if

the

hous

ehol

d in

com

e dr

ops b

elow

the

inco

me

limit.

10

. W

HAT

IF I

DISA

GREE

WIT

H TH

E SC

HOO

L’S

DECI

SIO

N AB

OUT

MY

APPL

ICAT

ION

? Yo

u sh

ould

talk

to sc

hool

offi

cials.

You

also

may

ask

for a

hea

ring

by c

allin

g or

writ

ing

to:

Mar

y Ro

bers

on, S

uper

inte

nden

t, 18

677

Old

Sta

te R

oad

37, L

eopo

ld, I

N 4

7551

, or b

y ph

one,

(812

) 843

-557

6, o

r by

emai

l mro

bers

on@

pccs

.k12

.in.u

s.

11.

MAY

I AP

PLY

IF S

OM

EONE

IN M

Y HO

USEH

OLD

IS N

OT

A U.

S. C

ITIZ

EN?

Yes.

You,

you

r chi

ldre

n, o

r oth

er h

ouse

hold

mem

bers

do

not h

ave

to b

e U.

S. ci

tizen

s to

appl

y fo

r fre

e or

redu

ced

price

mea

ls.

12.

WHA

T IF

MY

INCO

ME

IS N

OT

ALW

AYS

THE

SAM

E? Li

st th

e am

ount

that

you

nor

mal

ly re

ceiv

e. F

or e

xam

ple,

if y

ou n

orm

ally

mak

e $1

000

each

mon

th, b

ut y

ou m

issed

som

e w

ork

last

mon

th a

nd o

nly

mad

e $9

00, p

ut d

own

that

you

mad

e $1

000

per m

onth

. If

you

norm

ally

get

ove

rtim

e, in

clude

it, b

ut d

o no

t inc

lude

it if

you

onl

y w

ork

over

time

som

etim

es.

If yo

u ha

ve lo

st a

job

or h

ad y

our h

ours

or w

ages

redu

ced,

use

you

r cur

rent

inco

me.

13

. W

HAT

IF S

OM

E HO

USEH

OLD

MEM

BERS

HAV

E NO

INCO

ME

TO R

EPO

RT?

Hous

ehol

d m

embe

rs m

ay n

ot re

ceiv

e so

me

type

s of i

ncom

e w

e as

k yo

u to

repo

rt o

n th

e ap

plica

tion,

or m

ay n

ot re

ceiv

e in

com

e at

all.

Whe

neve

r thi

s hap

pens

, ple

ase

writ

e a

0 in

the

field

. How

ever

, if a

ny in

com

e fie

lds a

re le

ft em

pty

or b

lank

, tho

se w

ill a

lso b

e co

unte

d as

zero

es. P

leas

e be

car

eful

whe

n le

avin

g in

com

e fie

lds b

lank

, as w

e w

ill a

ssum

e yo

u m

eant

to d

o so

. 14

. W

E AR

E IN

THE

MIL

ITAR

Y. D

O W

E RE

PORT

OUR

INCO

ME

DIFF

EREN

TLY?

You

r bas

ic pa

y an

d ca

sh b

onus

es m

ust b

e re

port

ed a

s inc

ome.

If y

ou g

et a

ny ca

sh v

alue

allo

wan

ces

for o

ff-ba

se h

ousin

g, fo

od, o

r clo

thin

g, it

mus

t also

be

inclu

ded

as in

com

e. H

owev

er, i

f you

r hou

sing

is pa

rt o

f the

Mili

tary

Hou

sing

Priv

atiza

tion

Initi

ativ

e, d

o no

t inc

lude

yo

ur h

ousin

g al

low

ance

as i

ncom

e. A

ny a

dditi

onal

com

bat p

ay re

sulti

ng fr

om d

eplo

ymen

t is a

lso e

xclu

ded

from

inco

me.

15

. W

HAT

IF T

HERE

ISN’

T EN

OUG

H SP

ACE

ON

THE

APPL

ICAT

ION

FOR

MY

FAM

ILY?

List

any

add

ition

al h

ouse

hold

mem

bers

on

a se

para

te p

iece

of p

aper

, and

att

ach

it to

you

r ap

plica

tion.

Con

tact

Lor

a Hu

bert

, ECA

Tre

asur

er, 1

8677

Old

Sta

te R

oad

37, L

eopo

ld, I

N 4

7551

, or b

y ph

one

(812

) 843

-557

6, o

r by

emai

l lhu

bert

@pc

cs.k

12.in

.us

to re

ceiv

e a

seco

nd a

pplic

atio

n.

16.

MY

FAM

ILY

NEED

S M

ORE

HEL

P. A

RE T

HERE

OTH

ER P

ROGR

AMS

WE

MIG

HT A

PPLY

FO

R? T

o fin

d ou

t how

to a

pply

for S

NAP

(Foo

d St

amp)

or o

ther

ass

istan

ce b

enef

its,

cont

act y

our l

ocal

ass

istan

ce o

ffice

or c

all 1

-800

-403

-086

4.

If yo

u ha

ve o

ther

que

stio

ns o

r nee

d he

lp, c

all (

812)

843

-557

6.

Sinc

erel

y,

Mar

y Ro

bers

on

Supe

rinte

nden

t Pe

rry

Cent

ral C

omm

unity

Sch

ool C

orpo

ratio

n

Pare

nt Le

tter

/Inst

ruct

ions

- PY

201

9

HOW

TO

APP

LY F

OR

FREE

AND

RED

UCED

PRI

CE S

CHO

OL M

EALS

Pl

ease

use

thes

e in

stru

ctio

ns to

hel

p yo

u fil

l out

the

appl

icatio

n fo

r fre

e or

redu

ced

price

scho

ol m

eals.

You

onl

y ne

ed to

sub

mit

one

appl

icatio

n pe

r hou

seho

ld, e

ven

if yo

ur

child

ren

atte

nd m

ore

than

one

scho

ol in

Per

ry C

entr

al C

omm

unity

Sch

ool C

orpo

ratio

n. T

he a

pplic

atio

n m

ust b

e fil

led

out c

ompl

etel

y to

cert

ify y

our c

hild

ren

for f

ree

or re

duce

d pr

ice sc

hool

mea

ls. P

leas

e fo

llow

thes

e in

stru

ctio

ns in

ord

er! E

ach

step

of t

he in

stru

ctio

ns is

the

sam

e as

the

step

s on

your

app

licat

ion.

If a

t any

tim

e yo

u ar

e no

t sur

e w

hat t

o do

ne

xt, p

leas

e co

ntac

t Per

ry C

entr

al C

omm

unity

Sch

ool C

orpo

ratio

n, Lo

ra H

uber

t, EC

A Tr

easu

rer a

t (81

2) 8

43-5

576,

or b

y em

ail l

hube

rt@

pccs

.k12

.in.u

s.

PLEA

SE U

SE A

PEN

(NO

T A

PENC

IL) W

HEN

FIL

LING

OUT

THE

APP

LICA

TIO

N AN

D DO

YO

UR

BEST

TO

PRI

NT

CLEA

RLY.

STEP

2: D

O A

NY H

OUS

EHO

LD M

EMBE

RS C

URRE

NTLY

PAR

TICI

PATE

IN S

NAP

or T

ANF?

If

anyo

ne in

you

r hou

seho

ld (i

nclu

ding

you

) cur

rent

ly p

artic

ipat

es in

one

or m

ore

of th

e as

sista

nce

prog

ram

s list

ed b

elow

, you

r chi

ldre

n ar

e el

igib

le fo

r fre

e sc

hool

mea

ls:

Th

e Su

pple

men

tal N

utrit

ion

Assis

tanc

e Pr

ogra

m (S

NAP)

.

Tem

pora

ry A

ssist

ance

for N

eedy

Fam

ilies

(TAN

F).

STEP

1: L

IST

ALL I

NFAN

TS, C

HILD

REN,

AND

STU

DENT

S UP

TO

AND

INCL

UDIN

G GR

ADE

12 IN

THE

HO

USEH

OLD

Te

ll us

how

man

y in

fant

s, ch

ildre

n, a

nd sc

hool

stud

ents

live

in y

our h

ouse

hold

. The

y do

NO

T ha

ve to

be

rela

ted

to y

ou to

be

a pa

rt o

f you

r hou

seho

ld.

Who

shou

ld I

list h

ere?

Whe

n fil

ling

out t

his s

ectio

n, p

leas

e in

clude

ALL

mem

bers

in y

our h

ouse

hold

who

are

:

Child

ren

age

18 o

r und

er A

ND a

re su

ppor

ted

with

the

hous

ehol

d’s i

ncom

e;

In

you

r car

e un

der a

fost

er a

rran

gem

ent,

or q

ualif

y as

hom

eles

s, m

igra

nt, o

r run

away

you

th;

St

uden

ts a

tten

ding

Per

ry C

entr

al C

omm

unity

Sch

ool C

orpo

ratio

n, re

gard

less

of a

ge.

A) Li

st e

ach

child

’s n

ame.

Prin

t eac

h ch

ild’s

nam

e. U

se o

ne li

ne o

f the

app

licat

ion

for e

ach

child

. If t

here

are

mor

e ch

ildre

n pr

esen

t tha

n lin

es o

n th

e ap

plica

tion,

atta

ch a

seco

nd p

iece

of

pap

er w

ith a

ll re

quire

d in

form

atio

n fo

r the

ad

ditio

nal c

hild

ren.

B) Is

the

child

a st

uden

t at P

erry

Ce

ntra

l Com

mun

ity S

choo

l Co

rpor

atio

n? M

ark

‘Yes

’ or ‘

No’

unde

r the

colu

mn

title

d “S

tude

nt”

to te

ll us

whi

ch ch

ildre

n at

tend

Pe

rry

Cent

ral C

omm

unity

Sch

ool

Corp

orat

ion.

If y

ou m

arke

d ‘Y

es,’

writ

e th

e na

me

of th

e sc

hool

bu

ildin

g, b

irthd

ate,

and

gra

de

leve

l of t

he st

uden

t in

the

‘Gra

de’

colu

mn

to th

e rig

ht.

Is th

e ch

ild li

ving

with

par

ent o

r ca

reta

ker r

elat

ive?

Mar

k ‘Y

es’ o

r ‘N

o’ n

ext t

o ea

ch ch

ild.

C) D

o yo

u ha

ve a

ny fo

ster

child

ren?

If a

ny ch

ildre

n lis

ted

are

fost

er ch

ildre

n, m

ark

the

“Fos

ter C

hild

” bo

x nex

t to

the

child

’s na

me.

If y

ou a

re O

NLY

appl

ying

for f

oste

r chi

ldre

n, a

fter f

inish

ing

STEP

1,

go to

STE

P 4.

Fo

ster

child

ren

who

live

with

you

may

coun

t as

mem

bers

of y

our h

ouse

hold

and

shou

ld b

e lis

ted

on

your

app

licat

ion.

If y

ou a

re a

pply

ing

for b

oth

fost

er

and

non-

fost

er ch

ildre

n, g

o to

step

3.

D) A

re a

ny ch

ildre

n ho

mel

ess,

mig

rant

, or

runa

way

? If

you

belie

ve a

ny ch

ild

liste

d in

this

sect

ion

mee

ts th

is de

scrip

tion,

mar

k th

e “H

omel

ess,

Mig

rant

, Run

away

” box

nex

t to

the

child

’s na

me

and

com

plet

e al

l ste

ps o

f th

e ap

plica

tion.

Pare

nt Le

tter

/Inst

ruct

ions

- PY

201

9

A) I

f no

one

in y

our h

ouse

hold

par

ticip

ates

in a

ny o

f the

abo

ve

liste

d pr

ogra

ms:

Leav

e ST

EP 2

bla

nk a

nd g

o to

STE

P 3.

B) I

f any

one

in y

our h

ouse

hold

par

ticip

ates

in a

ny o

f the

abo

ve li

sted

pro

gram

s:

W

rite

a ca

se n

umbe

r for

SNA

P or

TAN

F. Y

ou o

nly

need

to p

rovi

de o

ne ca

se n

umbe

r. If

you

part

icipa

te in

one

of

thes

e pr

ogra

ms a

nd d

o no

t kno

w y

our c

ase

num

ber,

cont

act:

1-80

0-40

3-08

64.

Go

to S

TEP

4.

STEP

3: R

EPO

RT IN

COM

E FO

R AL

L HO

USEH

OLD

MEM

BERS

Ho

w d

o I r

epor

t my

inco

me?

Use

the

char

ts ti

tled

“Sou

rces

of I

ncom

e fo

r Adu

lts” a

nd “

Sour

ces o

f Inc

ome

for C

hild

ren,

” lo

cate

d be

low

to d

eter

min

e if

your

hou

seho

ld h

as in

com

e to

repo

rt.

R e p o r t a l l a m o unt

s in

GRO

SS IN

COM

E O

NLY.

Rep

ort a

ll in

com

e in

who

le d

olla

rs. D

o no

t inc

lude

cent

s.

o Gr

oss i

ncom

e is

the

tota

l inc

ome

rece

ived

bef

ore

taxe

s o

Man

y pe

ople

thin

k of

inco

me

as th

e am

ount

they

“tak

e ho

me”

and

not

the

tota

l, “g

ross

” am

ount

. Mak

e su

re th

at th

e in

com

e yo

u re

port

on

this

appl

icatio

n ha

s NO

T be

en

redu

ced

to p

ay fo

r tax

es, i

nsur

ance

pre

miu

ms,

or a

ny o

ther

am

ount

s tak

en fr

om y

our p

ay.

W

rite

a “0

” in

any

field

s whe

re th

ere

is no

inco

me

to re

port

. Any

inco

me

field

s lef

t em

pty

or b

lank

will

also

be

coun

ted

as a

zero

. If y

ou w

rite

‘0’ o

r lea

ve a

ny fi

elds

bla

nk, y

ou a

re

cert

ifyin

g (p

rom

ising

) tha

t the

re is

no

inco

me

to re

port

. If l

ocal

offi

cials

susp

ect t

hat y

our h

ouse

hold

inco

me

was

repo

rted

inco

rrec

tly, y

our a

pplic

atio

n w

ill b

e in

vest

igat

ed.

M

ark

how

ofte

n ea

ch ty

pe o

f inc

ome

is re

ceiv

ed u

sing

the

chec

k bo

xes t

o th

e rig

ht o

f eac

h fie

ld.

Sou

rces

of I

ncom

e fo

r C

hild

ren

Sour

ces o

f Chil

d Inc

ome

Exam

ple(s)

- E

arni

ngs

from

wor

k - A

chi

ld h

as a

regu

lar f

ull o

r par

t-tim

e jo

b w

here

they

ear

n a

sala

ry o

r wag

es

- So

cial

Sec

urity

-

Dis

abilit

y Pa

ymen

ts

- Su

rviv

or’s

Ben

efits

- A

chi

ld is

blin

d or

disa

bled

and

rece

ives

Socia

l Sec

urity

ben

efits

- A

Par

ent i

s di

sabl

ed, r

etire

d, o

r dec

ease

d,

and

thei

r chi

ld re

ceive

s So

cial S

ecur

ity

bene

fits

-Inco

me

from

per

son

outs

ide

the

hous

ehol

d - A

frie

nd o

r ext

ende

d fa

mily

m

embe

r reg

ular

ly g

ives

a c

hild

sp

endi

ng m

oney

-In

com

e fro

m a

ny o

ther

sou

rce

- A c

hild

rece

ives

regu

lar i

ncom

e fro

m a

priv

ate

pens

ion

fund

, ann

uity

, or

trus

t

Sou

rces

of I

ncom

e fo

r A

dults

Ea

rning

s fro

m W

ork

Publi

c Ass

istan

ce /

Alim

ony /

Chil

d Sup

port

Pens

ions /

Reti

rem

ent /

All

Othe

r Inco

me

- Sal

ary,

wag

es, c

ash

bonu

ses

- Net

inco

me

from

sel

f- em

ploy

men

t (fa

rm o

r bu

sine

ss)

If yo

u ar

e in

the

U.S

. Milit

ary:

- Bas

ic pa

y and

cash

bonu

ses

(do N

OT

includ

e com

bat p

ay,

FSSA

or p

rivat

ized h

ousin

g all

owan

ces)

- A

llowa

nces

for o

ff-ba

se

hous

ing, fo

od an

d clot

hing

- U

nem

ploy

men

t ben

efits

-

Wor

ker’s

com

pens

atio

n

- Sup

plem

enta

l Sec

urity

In

com

e (S

SI)

- C

ash

assi

stan

ce fr

om

Stat

e or

loca

l gov

ernm

ent

- A

limon

y pa

ymen

ts

- C

hild

sup

port

paym

ents

- Vet

eran

’s b

enefi

ts

- S

trike

ben

efits

- So

cial

Sec

urity

(inc

ludi

ng

railr

oad

retir

emen

t and

bla

ck

lung

ben

efits

) -

Priv

ate

pens

ions

or

disa

bilit

y be

nefit

s -

Reg

ular

inco

me

from

tru

sts

or e

stat

es

- An

nuiti

es

- In

vest

men

t inc

ome

- Ea

rned

inte

rest

-

Ren

tal i

ncom

e -

Reg

ular

cas

h pa

ymen

ts fr

om

outs

ide

hous

ehol

d

3.A.

REP

ORT

INCO

ME

EARN

ED B

Y CH

ILDR

EN

A) R

epor

t all

inco

me

earn

ed o

r rec

eive

d by

child

ren.

Rep

ort t

he co

mbi

ned

gros

s inc

ome

for A

LL ch

ildre

n lis

ted

in S

TEP

1 in

you

r hou

seho

ld in

the

box

mar

ked

“Chi

ld In

com

e.” O

nly

coun

t fos

ter c

hild

ren’

s inc

ome

if yo

u ar

e ap

plyi

ng fo

r the

m to

geth

er w

ith th

e re

st o

f you

r hou

seho

ld.

Wha

t is C

hild

Inco

me?

Chi

ld in

com

e is

mon

ey re

ceiv

ed fr

om o

utsid

e yo

ur h

ouse

hold

that

is p

aid

DIRE

CTLY

to y

our c

hild

ren.

Man

y ho

useh

olds

do

not h

ave

any

child

inco

me.

3.

B R

EPO

RT IN

COM

E EA

RNED

BY

ADUL

TS

Who

shou

ld I

list h

ere?

Whe

n fil

ling

out t

his s

ectio

n, p

leas

e in

clude

ALL

adu

lt m

embe

rs in

you

r hou

seho

ld w

ho a

re li

ving

with

you

and

shar

e in

com

e an

d ex

pens

es, e

ven

if th

ey a

re n

ot re

late

d an

d ev

en if

they

do

not r

ecei

ve in

com

e of

thei

r ow

n.

Do

NO

T in

clude

:

Pare

nt Le

tter

/Inst

ruct

ions

- PY

201

9

o Pe

ople

who

live

with

you

but

are

not

supp

orte

d by

you

r hou

seho

ld’s

inco

me

AND

do n

ot co

ntrib

ute

inco

me

to y

our h

ouse

hold

. o

Infa

nts,

Child

ren

and

stud

ents

alre

ady

liste

d in

STE

P 1.

B)

List

adu

lt ho

useh

old

mem

bers

’ na

mes

. Prin

t the

nam

e of

eac

h ho

useh

old

mem

ber i

n th

e bo

xes m

arke

d “N

ames

of A

dult

Hous

ehol

d M

embe

rs

(Firs

t and

Last

).” D

o no

t list

any

ho

useh

old

mem

bers

you

list

ed in

STE

P 1.

If

a ch

ild li

sted

in S

TEP

1 ha

s inc

ome,

fo

llow

the

inst

ruct

ions

in S

TEP

3, p

art A

.

C) R

epor

t ear

ning

s fro

m w

ork.

Rep

ort a

ll in

com

e fro

m w

ork

in th

e “E

arni

ngs f

rom

Wor

k” fi

eld

on th

e ap

plica

tion.

Thi

s is u

sual

ly th

e m

oney

rece

ived

from

wor

king

at j

obs.

If yo

u ar

e a

self-

empl

oyed

bu

sines

s or f

arm

ow

ner,

you

will

repo

rt y

our n

et in

com

e.

Wha

t if I

am

self-

empl

oyed

? Re

port

inco

me

from

that

wor

k as

a n

et

amou

nt. T

his i

s cal

cula

ted

by su

btra

ctin

g th

e to

tal o

pera

ting

expe

nses

of y

our b

usin

ess f

rom

its g

ross

rece

ipts

or r

even

ue.

D) R

epor

t inc

ome

from

pub

lic a

ssist

ance

/chi

ld

supp

ort/

alim

ony.

Rep

ort a

ll in

com

e th

at a

pplie

s in

the

“Pub

lic

Assis

tanc

e/Ch

ild S

uppo

rt/A

limon

y” fi

eld

on th

e ap

plica

tion.

Do

not r

epor

t the

cash

val

ue o

f any

pub

lic a

ssist

ance

ben

efits

NO

T lis

ted

on th

e ch

art.

If in

com

e is

rece

ived

from

child

supp

ort o

r al

imon

y, o

nly

repo

rt c

ourt

-ord

ered

pay

men

ts. I

nfor

mal

but

re

gula

r pay

men

ts sh

ould

be

repo

rted

as “

othe

r” in

com

e in

the

next

par

t.

E) R

epor

t inc

ome

from

pe

nsio

ns/r

etire

men

t/al

l oth

er in

com

e.

Repo

rt a

ll in

com

e th

at a

pplie

s in

the

“Pen

sions

/Ret

irem

ent/

All

Oth

er

Inco

me”

fiel

d on

the

appl

icatio

n.

F) R

epor

t tot

al h

ouse

hold

size

. Ent

er th

e to

tal n

umbe

r of h

ouse

hold

m

embe

rs in

the

field

“Tot

al H

ouse

hold

Mem

bers

(Chi

ldre

n an

d Ad

ults

).” T

his n

umbe

r MUS

T be

equ

al to

the

num

ber o

f hou

seho

ld

mem

bers

list

ed in

STE

P 1

and

STEP

3. I

f the

re a

re a

ny m

embe

rs o

f yo

ur h

ouse

hold

that

you

hav

e no

t list

ed o

n th

e ap

plica

tion,

go

back

an

d ad

d th

em. I

t is v

ery

impo

rtan

t to

list a

ll ho

useh

old

mem

bers

, as

the

size

of y

our h

ouse

hold

affe

cts y

our e

ligib

ility

for f

ree

and

redu

ced

price

mea

ls.

G) P

rovi

de th

e la

st fo

ur d

igits

of y

our S

ocia

l Sec

urity

Num

ber.

An a

dult

hous

ehol

d m

embe

r mus

t ent

er th

e la

st fo

ur d

igits

of

thei

r Soc

ial S

ecur

ity N

umbe

r in

the

spac

e pr

ovid

ed. Y

ou a

re

elig

ible

to a

pply

for b

enef

its e

ven

if yo

u do

not

hav

e a

Socia

l Se

curit

y Nu

mbe

r. If

no a

dult

hous

ehol

d m

embe

rs h

ave

a So

cial

Secu

rity

Num

ber,

leav

e th

is sp

ace

blan

k an

d m

ark

the

box t

o th

e rig

ht la

bele

d “C

heck

if n

o SS

N.”

STEP

4: C

ONT

ACT

INFO

RMAT

ION

AND

ADUL

T SI

GNAT

URE

All a

pplic

atio

ns m

ust b

e sig

ned

by a

n ad

ult m

embe

r of t

he h

ouse

hold

. By

signi

ng th

e ap

plica

tion,

that

hou

seho

ld m

embe

r is p

rom

ising

that

all

info

rmat

ion

has b

een

trut

hful

ly

and

com

plet

ely

repo

rted

. Bef

ore

com

plet

ing

this

sect

ion,

ple

ase

also

mak

e su

re y

ou h

ave

read

the

priv

acy

and

civil

right

s sta

tem

ents

on

the

back

of t

he a

pplic

atio

n.

A) P

rint a

nd si

gn y

our n

ame.

Prin

t the

na

me

of th

e ad

ult s

igni

ng th

e ap

plica

tion

and

that

per

son

signs

in th

e bo

x “S

igna

ture

of

adu

lt.”

B) P

rovi

de y

our c

onta

ct in

form

atio

n.

Writ

e yo

ur cu

rren

t add

ress

in th

e fie

lds

prov

ided

if th

is in

form

atio

n is

avai

labl

e. If

yo

u ha

ve n

o pe

rman

ent a

ddre

ss, t

his d

oes

not m

ake

your

child

ren

inel

igib

le fo

r fre

e or

redu

ced

price

scho

ol m

eals.

Sha

ring

a ph

one

num

ber,

emai

l add

ress

, or b

oth

is op

tiona

l, bu

t hel

ps u

s rea

ch y

ou q

uick

ly if

w

e ne

ed to

cont

act y

ou.

C) M

ail C

ompl

eted

For

m to

: Per

ry C

entr

al

Com

mun

ity S

choo

l Cor

pora

tion,

ATT

N:

Lora

Hub

ert,

ECA

Trea

sure

r, 18

677

Old

St

ate

Road

37,

Leop

old,

IN 4

7551

D) S

hare

child

ren’

s rac

ial a

nd e

thni

c id

entit

ies (

optio

nal).

On

the

back

of t

he

appl

icatio

n, w

e as

k yo

u to

shar

e in

form

atio

n ab

out y

our c

hild

ren’

s rac

e an

d et

hnici

ty. T

his f

ield

is o

ptio

nal a

nd d

oes

not a

ffect

you

r chi

ldre

n’s e

ligib

ility

for f

ree

or re

duce

d pr

ice sc

hool

mea

ls.

STEP

5: O

THER

BEN

EFIT

S –

OPT

IONA

L Th

e fo

llow

ing

sect

ions

are

opt

iona

l and

do

not a

ffect

you

r chi

ldre

n’s e

ligib

ility

for f

ree

or re

duce

d pr

ice sc

hool

mea

ls.

A) T

extb

ook

Assis

tanc

e If

you

wan

t to

rece

ive

text

book

ass

istan

ce, c

heck

‘Yes

’ and

then

read

, sig

n, a

nd d

ate

the

sect

ion

to th

e rig

ht. I

f you

do

not w

ant t

o re

ceiv

e te

xtbo

ok a

ssist

ance

, che

ck ‘N

o’.

B) H

oosie

r Hea

lthw

ise D

isclo

sure

If

you

wan

t to

shar

e yo

ur ch

ild’s

free/

redu

ced

elig

ibili

ty in

ord

er to

qua

lify

for f

ree

or

low

-cos

t hea

lth in

sura

nce

unde

r Med

icaid

or H

oosie

r Hea

lthw

ise, s

ign

and

date

this

sect

ion.

PER

RY

CEN

TRAL

CO

MM

UNI

TY S

CHO

OL

CORP

OR

ATIO

N

2018

-201

9 Ho

useh

old

Appl

icat

ion

for F

ree

and

Redu

ced

Pric

e Sc

hool

Mea

ls

Com

plet

e on

e ap

plic

atio

n pe

r hou

seho

ld. P

leas

e us

e a

pen

(not

a p

enci

l).

Pres

crib

ed b

y St

ate

Boar

d of

Acc

ount

s Sc

hool

For

m N

o. 5

21/2

018

STEP

1 Li

st A

LL in

fant

s, c

hild

ren,

and

stu

dent

s up

to g

rade

12

who

are

mem

bers

of y

our h

ouse

hold

(if m

ore

spac

es a

re re

quire

d fo

r add

itiona

l nam

es, a

ttach

ano

ther

she

et o

f pap

er)

Def

initi

on o

f Hou

seho

ld

Mem

ber:

“Any

one

who

is

livin

g w

ith y

ou a

nd s

hare

s in

com

e an

d ex

pens

es,

even

if n

ot re

late

d.”

Chi

ldre

n in

Fos

ter c

are

and

child

ren

who

mee

t the

de

finitio

n of

Hom

eles

s,

Mig

rant

or R

unaw

ay a

re

elig

ible

for f

ree

mea

ls. R

ead

How

to A

pply

for F

ree

and

Redu

ced

Pric

e Sc

hool

M

eals

for m

ore

info

rmat

ion.

Chi

ld’s

Firs

t Nam

e M

I C

hild

’s L

ast N

ame

Fost

er

Chi

ld

Hom

eles

s,

Mig

rant

, R

unaw

ay

Stud

ent?

Ye

s N

o

STEP

2

Do a

ny H

ouse

hold

Mem

bers

(inc

ludi

ng y

ou) c

urre

ntly

par

ticip

ate

in o

ne o

r mor

e of

the

follo

win

g as

sist

ance

pro

gram

s: S

NAP

(Foo

d St

amp)

or T

ANF?

If NO

> G

o to

STE

P 3.

If

YES

> W

rite

a ca

se n

umbe

r her

e th

en g

o to

STE

P 4

(Do

not c

ompl

ete

STEP

3)

Case

Num

ber:

/

/

/

/

/

/

/ /

/

Writ

e on

ly o

ne c

ase

num

ber i

n th

is s

pace

.

STEP

3

Repo

rt In

com

e fo

r ALL

Hou

seho

ld M

embe

rs (S

kip

this

ste

p if

you

answ

ered

‘Yes

’ to

STEP

2)

How

ofte

n?

A. C

hild

Inco

me

Som

etim

es c

hild

ren

in th

e ho

useh

old

earn

or r

ecei

ve in

com

e. P

leas

e in

clud

e th

e TO

TAL

inco

me

rece

ived

by

all c

hild

ren

in h

ouse

hold

list

ed in

STE

P 1

here

.

Child

inco

me

W

eekl

y

Ever

y 2

Wks

2

x M

onth

M

onth

ly

$ B.

All

Adul

t Hou

seho

ld M

embe

rs (i

nclu

ding

you

rsel

f) Li

st a

ll H

ouse

hold

Mem

bers

not

list

ed in

STE

P 1

(incl

udin

g yo

urse

lf) e

ven

if th

ey d

o no

t rec

eive

inco

me.

For

eac

h H

ouse

hold

Mem

ber l

iste

d, if

they

do

rece

ive

inco

me,

repo

rt to

tal (

gros

s) in

com

e be

fore

any

taxe

s or

ded

uctio

ns fo

r eac

h so

urce

in w

hole

dol

lars

(no

cent

s) o

nly.

If th

ey d

o no

t rec

eive

inco

me

from

any

sou

rce,

writ

e ‘0

’. If

you

ente

r ‘0’

or l

eave

any

fiel

ds b

lank

, you

are

cer

tifyi

ng

(pro

mis

ing)

that

ther

e is

no

inco

me

to re

port.

Ho

w of

ten?

Pu

blic

Ass

ista

nce/

C

hild

Sup

port/

Alim

ony

How

ofte

n?

Pens

ions

/Ret

irem

ent/

All O

ther

Inco

me

How

ofte

n?

Nam

e of

Adu

lt H

ouse

hold

Mem

bers

(Firs

t and

Las

t) Ea

rnin

gs fr

om W

ork

W

eekl

y E

very

2 W

ks 2

x M

onth

Mon

thly

$

$

$

$

$

$

$

$ $

$

$ $

$

$ $

Tota

l Hou

seho

ld M

embe

rs

(Chi

ldre

n an

d A

dults

) La

st F

our D

igits

of S

ocia

l Sec

urity

Num

ber (

SSN)

of

Prim

ary

Wag

e Ea

rner

or O

ther

Adu

lt Ho

useh

old

Mem

ber

X

X

X

X X

Ch

eck

if no

SSN

“I ce

rtify

(pro

mis

e) th

at a

ll in

form

atio

n on

this

app

licat

ion

is tr

ue a

nd th

at a

ll in

com

e is

repo

rted.

I un

ders

tand

that

thi

s in

form

atio

n is

giv

en in

con

nect

ion

with

the

rece

ipt o

f Fed

eral

fund

s, a

nd th

at s

choo

l offi

cial

s m

ay v

erify

(che

ck) t

he in

form

atio

n. I

am a

war

e th

at if

I pu

rpos

ely

give

fa

lse

info

rmat

ion,

my

child

ren

may

lose

mea

l ben

efits

, and

I m

ay b

e pr

osec

uted

und

er a

pplic

able

Sta

te a

nd F

eder

al la

ws.

”

Stre

et A

ddre

ss (i

f ava

ilabl

e)

Apt #

C

ity

Stat

e Zi

p D

aytim

e Ph

one

and

Emai

l (op

tiona

l)

Prin

ted

nam

e of

adu

lt co

mpl

etin

g th

e fo

rm

Sign

atur

e of

adu

lt co

mpl

etin

g th

e fo

rm

Toda

y’s d

ate

Con

tact

info

rmat

ion

and

adul

t sig

natu

re. M

ail C

ompl

eted

For

m T

o: 1

8677

Old

Sta

te R

oad

37, L

eopo

ld, I

N 4

7551

T

urn

for T

extb

ook

Ben

efits

W

eekl

y E

very

2 W

ks 2

x M

onth

Mon

thly

Onl

y St

uden

ts:

Birth

date

Onl

y St

uden

ts:

Gra

de

W

eekl

y E

very

2 W

ks 2

x M

onth

Mon

thly

Onl

y St

uden

ts:

Nam

e of

Sch

ool B

uild

ing

STEP

4

Livi

ng w

ith p

aren

t or

care

take

r rel

ativ

e?

Yes

No

Check all that apply

Are

you

unsu

re w

hat

to d

o he

re?

Pl

ease

read

How

to

App

ly fo

r Fre

e

and

Red

uced

Pric

e Sc

hool

Mea

ls fo

r m

ore

info

rmat

ion.

Th

e So

urce

s of

In

com

e fo

r Chi

ldre

n se

ctio

n w

ill he

lp

you

with

the

Chi

ld

Inco

me

ques

tion.

Th

e So

urce

s of

In

com

e fo

r Adu

lts

sect

ion

will

help

you

w

ith th

e A

ll A

dult

Hou

seho

ld M

embe

rs

sect

ion.

1 2 3 4 5

1 2 3 4 5

Do

you

wan

t to

rece

ive

Text

book

Ass

ista

nce?

OPT

IONA

L Ch

ildre

n's

Raci

al a

nd E

thni

c Id

entit

ies

We

are

requ

ired

to a

sk fo

r inf

orm

atio

n ab

out y

our c

hild

ren’

s ra

ce a

nd e

thni

city

. Thi

s in

form

atio

n is

impo

rtant

and

hel

ps to

mak

e su

re w

e ar

e fu

lly s

ervi

ng o

ur c

omm

unity

. Res

pond

ing

to th

is s

ectio

n is

opt

iona

l and

doe

s no

t affe

ct y

our c

hild

ren’

s el

igib

ility

for f

ree

or re

duce

d pr

ice

mea

ls.

Ethn

icity

(che

ck o

ne):

Race

(che

ck o

ne o

r mor

e):

His

pani

c or

Lat

ino

Not

His

pani

c or

Lat

ino

Amer

ican

Indi

an o

r Ala

skan

Nat

ive

Asia

n

Blac

k or

Afri

can

Amer

ican

STEP

5

Oth

er B

enef

its –

Thi

s se

ctio

n do

es n

ot n

eed

to b

e co

mpl

eted

to re

ceiv

e fre

e or

redu

ced

pric

e m

eal b

enef

its.

Yes

N

o If

yes,

sig

n to

the

righ

t

I cer

tify

that

I am

the

pare

nt/g

uard

ian

of th

e ch

ild(r

en) f

or w

hom

app

licat

ion

is b

ein

g m

ade.

My

sign

atur

e be

low

aut

horiz

es th

e re

leas

e of

in

form

atio

n on

this

app

licat

ion

for t

extb

ook

assi

stan

ce. I

giv

e up

my

right

of c

onfid

entia

lity

for t

his

purp

ose

only

. Thi

s ap

plic

atio

n in

form

atio

n w

ill b

e sh

ared

with

the

Indi

ana

Fam

ily a

nd S

ocia

l Ser

vice

s A

dmin

istra

tion

purs

uant

to I.

C. 2

0-33

-5-2

and

I.C

. 12-

14-2

8-2,

so

lely

for p

urpo

ses

of c

ompl

ying

with

45

C.F

.R. P

arts

260

and

265

.

Sign

atur

e of

adu

lt co

mpl

etin

g th

e fo

rm

Toda

y’s d

ate

Sch

ool U

se O

nly:

�

App

rove

d �

Den

ied

�

Not

App

licab

le

Th

is a

pplic

atio

n in

form

atio

n m

ay b

e sh

ared

with

the

Fam

ily a

nd S

ocia

l Ser

vice

s A

dmin

istra

tion

for t

he p

urpo

se o

f ide

ntify

ing

child

ren

who

may

qua

lify

for f

ree

or lo

w-c

ost h

ealth

insu

ranc

e un

der

Med

icai

d or

Hoo

sier

H

ealth

wis

e . If

you

wan

t the

app

licat

ion

info

rmat

ion

shar

ed fo

r thi

s pu

rpos

e, p

leas

e si

gn b

elow

. I c

ertif

y I a

m th

e pa

rent

/gua

rdia

n of

the

chi

ld(r

en) f

or w

hom

app

licat

ion

is b

eing

mad

e. I

auth

oriz

e th

e re

leas

e of

in

form

atio

n fo

r thi

s pu

rpos

e.

Sign

atur

e of

adu

lt co

mpl

etin

g th

e fo

rm

Toda

y’s d

ate

For i

nfor

mat

ion

abou

t Hoo

sier

Hea

lthw

ise

heal

th in

sura

nce,

ca

ll 1-

800-

889-

9949

.

Nat

ive

Haw

aiia

n or

Oth

er P

acifi

c Is

land

er

Whi

te

5

Pers

ons

with

dis

abilit

ies

who

requ

ire a

ltern

ativ

e m

eans

of c

omm

unic

atio

n fo

r pro

gram

info

rmat

ion

(e.g

. Bra

ille,

larg

e pr

int,

audi

otap

e, A

mer

ican

Sig

n La

ngua

ge, e

tc.),

sho

uld

cont

act t

he A

genc

y (S

tate

or l

ocal

) whe

re th

ey

appl

ied

for

bene

fits.

Indi

vidu

als

who

are

dea

f, ha

rd o

f hea

ring

or h

ave

spee

ch d

isab

ilitie

s m

ay c

onta

ct U

SDA

thro

ugh

the

Fede

ral

Rel

ay S

ervi

ce a

t (8

00)

877-

8339

. Ad

ditio

nally

, pr

ogra

m i

nfor

mat

ion

may

be

mad

e av

aila

ble

in

lang

uage

s ot

her t

han

Engl

ish.

To

file

a p

rogr

am c

ompl

aint

of d

iscr

imin

atio

n, c

ompl

ete

the

USD

A Pr

ogra

m D

iscr

imin

atio

n C

ompl

aint

Fo

rm,

(AD

-302

7) fo

und

onlin

e at

: http

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ww

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r.usd

a.go

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mpl

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t any

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A of

fice,

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e a

lette

r add

ress

ed to

USD

A an

d pr

ovid

e in

the

lette

r all o

f the

info

rmat

ion

requ

este

d in

the

form

. To

requ

est a

cop

y of

the

com

plai

nt fo

rm, c

all (

866)

632

-999

2. S

ubm

it yo

ur c

ompl

eted

form

or l

ette

r to

USD

A by

: m

ail:

U.S

. Dep

artm

ent o

f Agr

icul

ture

Offi

ce o

f the

Ass

ista

nt S

ecre

tary

for C

ivil

Rig

hts

1400

Inde

pend

ence

Ave

nue,

SW

Was

hing

ton,

D.C

. 202

50-9

410

fax:

(

202)

690

-744

2; o

r em

ail:

pro

gram

.inta

ke@

usda

.gov

Th

is in

stitu

tion

is a

n eq

ual o

ppor

tuni

ty p

rovi

der.

The

Ric

hard

B. R

usse

ll N

atio

nal S

choo

l Lun

ch A

ct re

quire

s th

e in

form

atio

n on

this

app

licat

ion.

You

do

not

have

to g

ive

the

info

rmat

ion,

but

if y

ou d

o no

t, w

e ca

nnot

app

rove

you

r chi

ld fo

r fre

e or

redu

ced

pric

e m

eals

. Yo

u m

ust i

nclu

de th

e la

st fo

ur d

igits

of t

he s

ocia

l sec

urity

num

ber o

f the

adu

lt ho

useh

old

mem

ber w

ho s

igns

the

appl

icat

ion.

The

last

four

dig

its o

f the

soc

ial s

ecur

ity n

umbe

r is

not r

equi

red

whe

n yo

u ap

ply

on b

ehal

f of a

fost

er

child

or y

ou li

st a

Sup

plem

enta

l Nut

ritio

n As

sist

ance

Pro

gram

(SN

AP),

Tem

pora

ry A

ssis

tanc

e fo

r Nee

dy

Fam

ilies

(TAN

F) P

rogr

am o

r Foo

d D

istri

butio

n Pr

ogra

m o

n In

dian

Res

erva

tions

(FD

PIR

) cas

e nu

mbe

r or o

ther

FD

PIR

iden

tifier

for y

our c

hild

or w

hen

you

indi

cate

that

the

adul

t hou

seho

ld m

embe

r sig

ning

the

appl

icat

ion

does

not

hav

e a

soci

al s

ecur

ity n

umbe

r. W

e w

ill us

e yo

ur in

form

atio

n to

det

erm

ine

if yo

ur c

hild

is e

ligib

le fo

r fre

e or

redu

ced

pric

e m

eals

, and

for a

dmin

istra

tion

and

enfo

rcem

ent o

f the

lunc

h an

d br

eakf

ast p

rogr

ams.

We

MA

Y sh

are

your

elig

ibilit

y in

form

atio

n w

ith e

duca

tion,

hea

lth, a

nd n

utrit

ion

prog

ram

s to

hel

p th

em e

valu

ate,

fund

, or

dete

rmin

e be

nefit

s fo

r the

ir pr

ogra

ms,

aud

itors

for p

rogr

am re

view

s, a

nd la

w e

nfor

cem

ent o

ffici

als

to h

elp

them

lo

ok in

to v

iola

tions

of p

rogr

am ru

les.

In

acc

orda

nce

with

Fed

eral

civ

il rig

hts

law

and

U.S

. Dep

artm

ent o

f Agr

icul

ture

(USD

A) c

ivil

right

s re

gula

tions

and

po

licie

s, th

e U

SDA,

its

Age

ncie

s, o

ffice

s, a

nd e

mpl

oyee

s, a

nd in

stitu

tions

par

ticip

atin

g in

or a

dmin

iste

ring

USD

A pr

ogra

ms

are

proh

ibite

d fro

m d

iscr

imin

atin

g ba

sed

on ra

ce, c

olor

, nat

iona

l orig

in, s

ex, d

isab

ility

, age

, or r

epris

al

or re

talia

tion

for p

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ivil

right

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tivity

in a

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rogr

am o

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ivity

con

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FOR

SC

HO

OL

USE

ON

LY –

DO

NO

T W

RIT

E B

ELO

W T

HIS

LIN

E IN

CO

ME

CO

NVE

RS

ION

to Y

EAR

LY:

WEE

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X 52

EV

ERY

2 W

EEKS

X 2

6 TW

ICE

A M

ON

TH X

24

MO

NTH

LY X

12

ELIG

IBIL

ITY

DETE

RMIN

ATIO

N

Inco

me

Elig

ibilit

y: T

otal

Hou

seho

ld S

ize:

____

__

Tota

l Inc

ome:

$___

____

____

pe

r: �

Wee

kly

� E

very

2 W

eeks

�

Mon

thly

�

Tw

ice

a M

onth

� Y

early

OR

Cat

egor

ical

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ibilit

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Foo

d St

amps

/TAN

F

� M

igra

nt

�

Hom

eles

s

�

Run

away

� F

oste

r El

igib

ility

Det

erm

inat

ion:

� A

ppro

ved

Free

�

App

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educ

ed P

rice

�

Den

ied

R

easo

n fo

r Den

ial:

� In

com

e To

o H

igh

�

Inco

mpl

ete

Appl

icat

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�

Oth

er__

____

____

____

____

____

_ Ty

pe o

f Elig

ibili

ty N

otifi

catio

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ovid

ed (i

f den

ied,

not

ifica

tion

mus

t be

writ

ten)

: �

Verb

al �

Writ

ten

Dat

e:__

____

____

Si

gnat

ure

of D

eter

min

ing

Offi

cial

: ___

____

____

____

____

____

____

____

____

____

____

____

Dat

e:__

____

____

__

Dat

e W

ithdr

awn:

___

____

____

___

VERI

FIC

ATIO

N

Con

firm

atio

n R

evie

w O

ffici

al: _

____

____

____

____

____

____

____

____

____

____

____

__ A

pplic

atio

n D

irect

Ver

ified

? Ye

s �

No

�

Dat

e V

erifi

catio

n N

otic

e Se

nt:_

____

____

____

___

Dat

e R

espo

nse

Due

from

Hou

seho

lds:

____

____

__

Dat

e S

econ

d N

otic

e S

ent (

or N

/A):

____

____

____

_

Appr

oval

Bas

ed O

n:

� Fo

od S

tam

ps /

TAN

F C

ase

Num

ber

� H

ouse

hold

Siz

e an

d In

com

e �

Oth

er _

____

____

Verif

icat

ion

Res

ults

: �

No

Cha

nge

� Fr

ee to

Red

uced

�

Free

to P

aid

� R

educ

ed to

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e �

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to P

aid

Rea

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hang

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com

e:__

____

____

____

__

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ouse

hold

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____

____

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nge

in F

ood

Stam

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id n

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spon

d �

Oth

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____

____

____

____

Dat

e N

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e of

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nge

Sent

:___

____

___

Dat

e C

hang

e M

ade:

____

____

_

Req

uest

for A

ppea

l D

ate

Hea

ring

Req

uest

ed:_

____

____

____

____

H

earin

g D

ecis

ion:

___

____

____

____

____

____

Verif

ying

Offi

cial

's S

igna

ture

:___

____

____

____

____

____

____

____

____

____

____

____

_ D

ate:

____

____

____

____

____

____

___