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Mary Queen of Apostles School

2021-2022 Free & Reduced Lunch Application

PLEASE NOTE:

This application is NOT AFFILIATED with the National School Lunch Program.

 A random application will be selected for verification in November 2021.

STEP 1: Please select Minor(s) below to continue, and then select how many Household Members (who are infants, children, and students up to and including grade 12.)
Minor(s)
1 Minor2 Minors3 Minors4 Minors5 MinorsMore Minors6 Minors7 Minors8 Minors9 Minors10 Minors
Continue
First Household Member's Name

First Name*

Last Name*
First Household Member's Date of Birth*
I certify that I am 18 years of age or older
First Household Member's Information
Grade Level*
Student?*
Yes
No
Indicate if Foster, Homeless, Migrant, or Runaway
Foster
Homeless
Migrant
Runaway
First Household Member's Signature*
Second Household Member's Name

First Name*

Last Name*
Second Household Member's Date of Birth*
Second Household Member's Information
Grade Level*
Student?*
Yes
No
Indicate if Foster, Homeless, Migrant, or Runaway
Foster
Homeless
Migrant
Runaway
Third Household Member's Name

First Name*

Last Name*
Third Household Member's Date of Birth*
Third Household Member's Information
Grade Level*
Student?*
Yes
No
Indicate if Foster, Homeless, Migrant, or Runaway
Foster
Homeless
Migrant
Runaway
Fourth Household Member's Name

First Name*

Last Name*
Fourth Household Member's Date of Birth*
Fourth Household Member's Information
Grade Level*
Student?*
Yes
No
Indicate if Foster, Homeless, Migrant, or Runaway
Foster
Homeless
Migrant
Runaway
Fifth Household Member's Name

First Name*

Last Name*
Fifth Household Member's Date of Birth*
Fifth Household Member's Information
Grade Level*
Student?*
Yes
No
Indicate if Foster, Homeless, Migrant, or Runaway
Foster
Homeless
Migrant
Runaway
Sixth Household Member's Name

First Name*

Last Name*
Sixth Household Member's Date of Birth*
Sixth Household Member's Information
Grade Level*
Student?*
Yes
No
Indicate if Foster, Homeless, Migrant, or Runaway
Foster
Homeless
Migrant
Runaway
Seventh Household Member's Name

First Name*

Last Name*
Seventh Household Member's Date of Birth*
Seventh Household Member's Information
Grade Level*
Student?*
Yes
No
Indicate if Foster, Homeless, Migrant, or Runaway
Foster
Homeless
Migrant
Runaway
Eighth Household Member's Name

First Name*

Last Name*
Eighth Household Member's Date of Birth*
Eighth Household Member's Information
Grade Level*
Student?*
Yes
No
Indicate if Foster, Homeless, Migrant, or Runaway
Foster
Homeless
Migrant
Runaway
Ninth Household Member's Name

First Name*

Last Name*
Ninth Household Member's Date of Birth*
Ninth Household Member's Information
Grade Level*
Student?*
Yes
No
Indicate if Foster, Homeless, Migrant, or Runaway
Foster
Homeless
Migrant
Runaway
Tenth Household Member's Name

First Name*

Last Name*
Tenth Household Member's Date of Birth*
Tenth Household Member's Information
Grade Level*
Student?*
Yes
No
Indicate if Foster, Homeless, Migrant, or Runaway
Foster
Homeless
Migrant
Runaway
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Parent or Guardian's Daytime Phone

Phone ( ___-___-____ ) *
STEP 2: Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP or TANF?
NO
YES

If NO - Go to STEP 3

If YES - Type a case number below and skip STEP 3


9 Digit Case Number
STEP 3: Report Income for ALL Household Members (skip this step if you answered "YES" to STEP 2)

Find your family size and the annual gross income level (before taxes) listed beside it on the charts below:

Family Size   Annual Reduced Rate

1*                   $ 23,606
2                    $ 31,894
3                    $ 40,182
4                    $ 48,470
5                    $ 56,758
6                    $ 65,046
7                    $ 73,334
8                    $ 81,622

For each additional family member add +$ 8,288

Family Size   Annual Free Rate
1*                   $ 16,588
2                    $ 22,412
3                    $ 28,236
4                    $ 34,060
5                    $ 39,884
6                    $ 45,708
7                    $ 51,532
8                    $ 57,356

For each additional family member add +$ 5,824

Family Size

Income Rate
Sources of Income
Sources of Income For Children:
  • Earnings from work (A child has a regular full or part-time job where they earn a salary or wages.)
  • Social Security/Disability Payments/Survivor's Benefits (A child is blind or disabled and receives Social Security benefits; A parent is disabled, retired, or deceased and their child receives Social Security benefits.)

  • Income from person outside the household (A friend or extended family member regularly gives a child spending money.)

  • Income from any other source (A child receives regular income from a private pension fund, annuity, or trust.)

Sources of Income For Adults:
Earnings from Work
  • Gross Salary, wages, cash bonuses
  • Net income from self-employment (farm or business)
  • Reporting Annual Income is allowable for seasonal or self-employment
If you are in the U.S. Military:
  • Basic pay and cash bonuses

    (do NOT include combat pay, FSSA, or privatized housing allowances)

  • Allowances for off-base housing, food, and clothing

Public Assistance/Alimony/Child Support

  • Unemployment benefits
  • Worker's Compensation
  • SupplementalSecurity Income (SSI)
  • Cash assistance from State or local government
  • Alimony payments
  • Child support payments
  • Veteran's benefits
  • Strike benefits
Pensions/Retirement/All Other Income
  • Soc Sec including railroad retirement/black lung benefits
  • Private pensions or disability benefits
  • Regular income from trusts or estates
  • Annuities Investment income
  • Earned interest
  • Rental income
  • Regular cash payments from outside household
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Grade Level*
Student?*
Yes
No
Indicate if Foster, Homeless, Migrant, or Runaway
Foster
Homeless
Migrant
Runaway
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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