Hickory Public Schools Application For Free and Reduced Price Meals<= /title> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"City"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"place"/>  <style>  </style>  </head> <body lang=3DEN-US style=3D'tab-interval:.5in'> <div class=3DSection1> <st1:City w= :st=3D"on"><st1:place w:st=3D"on">HICKORY</st1:pl= ace></st1:City> PUBLIC SCHOOLS FREE AND REDUCED PRICE SCHOOL ME= ALS FAMILY APPLICATION<o:p></o:p> 2008-2009 SCHOOL YEAR<o:p></o:p> = <= /span><o:p></o:p><= /b> <h2>Part 1: Student Information- Please Print As Registered In School</u= > &= nbsp; &nbs= p; = Food Stamp or TANF C= ase Number<o:p></o:p></h2> <h1>Names of = ALL School Age Children = &nb= sp; = School Grade &= nbsp; &nbs= p; (EBT card number NOT acceptable)<o:p></o:p></h1> <h1> = (First, Middle Initial, Last) = = ; &n= bsp; = ; = &nb= sp; = (ski= p to part 5 if you list food stamp or tanf#)<= u><o:= p></o:p></h1> 1. &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; </span= ><o:p></o:p> 2. &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; </span= ><o:p></o:p> <![if !vml]><img width=3D534 height=3D140 src=3D"08-09lunchapp_files/image001.gif" alt=3D"ONE PER FAMILY" v:shapes=3D= "_x0000_s1032"><![endif]>3. = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &= nbsp; &nbs= p; <o:p></o:p> 4. &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; </span= ><o:p></o:p> 5. &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; </span= ><o:p></o:p> 6. &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; </span= ><o:p></o:p> 7. &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; </span= ><o:p></o:p> ----------------------------------------------------------------------= ---------------------------------------------------------------------------= -------------------<o:p></o:p> Part 2. If the child you are applying for is homeless, migrant, or a runaway che= ck the appropriate box and call 828-322-2855 extension 229 Homeless = ÿ<= /span> Migrant </= span>ÿ<= /span> </spa= n>Runaway = ÿ<o:p></o:p> -----------------------------------------------------------------------= ---------------------------------------------------------------------------= ---------------------------------------------------------------------------= --------------<o:p></o:p> <h2>Part 3. Foster Child (USE A SEPARATE APPLICATION FOR EACH FOSTER CHILD)= </h2> If this application is for a child who is the legal responsibility of a welfare agency or court, check this box <span style=3D'font-size:10.0pt; mso-bidi-font-size:12.0pt;font-family:Symbol;mso-ascii-font-family:"Times N= ew Roman"; mso-hansi-font-family:"Times New Roman";mso-char-type:symbol;mso-symbol-fon= t-family: Symbol'>= ÿ and then list the amou= nt of the child’s personal use monthly income: $ &= nbsp; &nbs= p; .___ per_______. Skip to par= t 5. <o:p></o:p> ----------------------------------------------------------------------= ---------------------------------------------------------------------------= -------------------<o:p></o:p> <h2>Part 4. Total Household Gross Income---If any child or adul= t in the household has no income, you MUST check the “No Income” Box in question 3 on= the application: if the box is not checked, the application will not <sp= an style=3D'font-weight:normal;mso-bidi-font-weight:bold'>be approved.<= /h2> <table class=3DMsoNormalTable border=3D1 cellspacing=3D0 cellpadding=3D0 style=3D'border-collapse:collapse;border:none;mso-border-alt:solid windowt= ext .5pt; mso-padding-alt:0in 5.4pt 0in 5.4pt;mso-border-insideh:.5pt solid windowte= xt; mso-border-insidev:.5pt solid windowtext'> <tr style=3D'mso-yfti-irow:0;mso-yfti-firstrow:yes;page-break-inside:avoid= '> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <![if !supportLists]>1. = <![endif]>Name <o:p></o:p></sp= an> (List everyone in<o:p></o:p></span= > household)<o:p></o:p></= p> </td> <td width=3D456 colspan=3D4 valign=3Dtop style=3D'width:4.75in;border:sol= id windowtext 1.0pt; border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt: solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> 2. Gross Income and how often received (Use exact income including cents.<sp= an style=3D'font-size:9.0pt'>) <o:p></o:p> Example: $100.15 per month, $100.97 twice a month, $100.76 every other week, $100 = per week<o:p></o:p> <table class=3DMsoNormalTable border=3D1 cellspacing=3D0 cellpadding=3D0 style=3D'border-collapse:collapse;border:none;mso-border-alt:solid windo= wtext .5pt; mso-padding-alt:0in 5.4pt 0in 5.4pt;mso-border-insideh:.5pt solid window= text; mso-border-insidev:.5pt solid windowtext'> <tr style=3D'mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:yes; height:26.5pt'> <td width=3D112 valign=3Dtop style=3D'width:84.35pt;border:solid window= text 1.0pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt; height:26.5pt'> Earnings from work before deductions<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border:solid windowt= ext 1.0pt; border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-a= lt: solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:26.5pt'> Welfare, child support, alimony<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border:solid windowt= ext 1.0pt; border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-a= lt: solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:26.5pt'> Pensions, retirement, Social Security<o:p></o:p> </td> <td width=3D202 valign=3Dtop style=3D'width:151.5pt;border:solid window= text 1.0pt; border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-a= lt: solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:26.5pt'> All Other Income<o:p></o:p> </td> </tr> </table> <o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border:solid windowtext= 1.0pt; border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt: solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> 3. Check if NO income<o:p>= </o:p> </td> </tr> <tr style=3D'mso-yfti-irow:1'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt'> Example:<o:p></o:p> Jane Smith<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $200.50 per week<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $100.75 per week<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $100.45 per month<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <span style=3D'font-size:16.0pt;mso-bidi-font-siz= e:12.0pt; font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi-font= -family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'><sp= an style=3D'mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ</span= ><o:p></o:p></= b> </td> </tr> <tr style=3D'mso-yfti-irow:2'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt'> <o:p> </o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <span style=3D'font-size:16.0pt;mso-bidi-font-siz= e:12.0pt; font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi-font= -family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'><sp= an style=3D'mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ</span= ><o:p></o:p></= b> </td> </tr> <tr style=3D'mso-yfti-irow:3'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt'> <o:p> </o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <span style=3D'font-size:16.0pt;mso-bidi-font-siz= e:12.0pt; font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi-font= -family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'><sp= an style=3D'mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ</span= ><o:p></o:p></= b> </td> </tr> <tr style=3D'mso-yfti-irow:4'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt'> <o:p> </o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <span style=3D'font-size:16.0pt;mso-bidi-font-siz= e:12.0pt; font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi-font= -family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'><sp= an style=3D'mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ</span= ><o:p></o:p></= b> </td> </tr> <tr style=3D'mso-yfti-irow:5'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt'> <o:p> </o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <span style=3D'font-size:16.0pt;mso-bidi-font-siz= e:12.0pt; font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi-font= -family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'><sp= an style=3D'mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ</span= ><o:p></o:p></= b> </td> </tr> <tr style=3D'mso-yfti-irow:6'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt'> <o:p> </o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <span style=3D'font-size:16.0pt;mso-bidi-font-siz= e:12.0pt; font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi-font= -family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'><sp= an style=3D'mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ</span= ><o:p></o:p></= b> </td> </tr> <tr style=3D'mso-yfti-irow:7'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt'> <o:p> </o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <span style=3D'font-size:16.0pt;mso-bidi-font-siz= e:12.0pt; font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi-font= -family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'><sp= an style=3D'mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ</span= ><o:p></o:p></= b> </td> </tr> <tr style=3D'mso-yfti-irow:8'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt'> <o:p> </o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <span style=3D'font-size:16.0pt;mso-bidi-font-siz= e:12.0pt; font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi-font= -family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'><sp= an style=3D'mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ</span= ><o:p></o:p></= b> </td> </tr> <tr style=3D'mso-yfti-irow:9;mso-yfti-lastrow:yes;height:3.5pt'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt;height:3.5pt'> &nbs= p; <o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:3= .5pt'> <o:p> </o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:3= .5pt'> <o:p> </o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:3= .5pt'> <o:p> </o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:3= .5pt'> <o:p> </o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:3= .5pt'> <o:p> </o:p> </td> </tr> </table> Part 5. Signature and Social Security Number (Ad= ult must sign)<o:p></o:p> An adult household member must sign the application.= If Part 4 is completed, the adult signing the form must also list his or her Social Security Number or Mark t= he “ I do not have a Social Security Number” box. (See Privacy Act Statement on the back of this page.) I certify (promise) that all information on this application is true and that= all income is reported. I understand that the school will get Federal funds bas= ed on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may = lose meal benefits, and I may be prosecuted. <o:p></o:p> Sign here: X_____________________________________ Print Name: ____________________________= _<o:p></o:p> Address: ______________________________________________Phone Number_______________________ Social Security Number: __ __ __- __ __-__ __ __ __ <span style=3D'font-size:11.0pt;mso-bidi= -font-size: 12.0pt;font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi= -font-family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ<= /span> I do not have a Social Security Number &nb= sp; Date _______________<o= :p></o:p> ----------------------------------------------------------------------= ---------------------------------------------------------------------------= -------------------<o:p></o:p> Part 6. Children’s racial and ethnic Identities (Optional)<o:p></o:p> Mark one or more racial identities: = ÿ Asian </s= pan>= ÿ White </s= pan>= ÿ Black= or African American </span= >= ÿ Ameri= can Indian or Alaska Native<o:p></o:p> = ÿ Native Hawaiian or Other Pacific Islander ÿ Other<o:p>= </o:p> Mark one ethnic Identi= ty: &= nbsp; &nbs= p; = ÿ Hispanic or Latino </sp= an>= ÿ Not Hispanic or Latino<o:p></o:p> <table class=3DMsoNormalTable border=3D1 cellspacing=3D0 cellpadding=3D0 wi= dth=3D832 style=3D'width:624.0pt;margin-left:-42.6pt;border-collapse:collapse;border= :none; mso-border-alt:solid windowtext .5pt;mso-padding-alt:0in 5.4pt 0in 5.4pt'> <tr style=3D'mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:yes; page-break-inside:avoid;height:71.5pt'> <td width=3D832 valign=3Dtop style=3D'width:624.0pt;border:solid windowte= xt 1.0pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:7= 1.5pt'> Don’t fill out this part.&n= bsp; This is for school use only.<o:p></o:p> Annual Income Conversion: Weekly = x 52, Every 2 Weeks x 26, Twice A Month x 24 Monthly x 12 <o:p></o:p> T &nbs= p; Total Income: ____________ Per: <span style=3D'font-size:8.= 0pt; font-family:Wingdings;mso-ascii-font-family:"Times New Roman";mso-hansi-f= ont-family: "Times New Roman";mso-bidi-font-family:Arial;mso-char-type:symbol;mso-sym= bol-font-family: Wingdings'>q Week, <span style=3D'font-size:8.0pt;font-family:Wingdings;mso-ascii-font-family:"Tim= es New Roman"; mso-hansi-font-family:"Times New Roman";mso-bidi-font-family:Arial; mso-char-type:symbol;mso-symbol-font-family:Wingdings'>q<= /span> Every 2 Weeks, </sp= an><span style=3D'font-size:8.0pt;font-family:Wingdings;mso-ascii-font-family:"Tim= es New Roman"; mso-hansi-font-family:"Times New Roman";mso-bidi-font-family:Arial; mso-char-type:symbol;mso-symbol-font-family:Wingdings'>q<= /span> Twice A Month, </sp= an><span style=3D'font-size:8.0pt;font-family:Wingdings;mso-ascii-font-family:"Tim= es New Roman"; mso-hansi-font-family:"Times New Roman";mso-bidi-font-family:Arial; mso-char-type:symbol;mso-symbol-font-family:Wingdings'>q<= /span> Month, <span style=3D'font-size:8.0pt;font-family:Wingdings;mso-ascii-font-family:"Tim= es New Roman"; mso-hansi-font-family:"Times New Roman";mso-bidi-font-family:Arial; mso-char-type:symbol;mso-symbol-font-family:Wingdings'>q<= /span> Year Household size: ________ <o:p></o:p> C &nbs= p; Categorical Eligibility: ___ Date Withdrawn: ________Eligibility: Free___ Reduced___ Denied___ Reason: _______________________<o:p></o:p> T &nbs= p; Temporary: Free_____ Reduced_____ Time Pe= riod: ___________ (expires after _____ days)<o:p></o:p> D &nbs= p; Determining Official’s Signature:___________________________= __________________ DDate: ______________<o:p></o:p> C &nbs= p; Confirming Official’s Signature: __________________ Date: _______ Follow-up Official’s Signature: __________________ Date: __= ____<o:p></o:p> </td> </tr> </table> <o:p> </o:p> </div> </body> 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MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01C91403.9C7E9A90" This document is a Single File Web Page, also known as a Web Archive file. If you are seeing this message, your browser or editor doesn't support Web Archive files. Please download a browser that supports Web Archive, such as Microsoft Internet Explorer. ------=_NextPart_01C91403.9C7E9A90 Content-Location: file:///C:/22659270/08-09lunchapp.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Hickory Public Schools Application For Free and Reduced Price Meals<= /title> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"City"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"place"/>  <style>  </style>  </head> <body lang=3DEN-US style=3D'tab-interval:.5in'> <div class=3DSection1> <st1:City w= :st=3D"on"><st1:place w:st=3D"on">HICKORY</st1:pl= ace></st1:City> PUBLIC SCHOOLS FREE AND REDUCED PRICE SCHOOL ME= ALS FAMILY APPLICATION<o:p></o:p> 2008-2009 SCHOOL YEAR<o:p></o:p> = <= /span><o:p></o:p><= /b> <h2>Part 1: Student Information- Please Print As Registered In School</u= > &= nbsp; &nbs= p; = Food Stamp or TANF C= ase Number<o:p></o:p></h2> <h1>Names of = ALL School Age Children = &nb= sp; = School Grade &= nbsp; &nbs= p; (EBT card number NOT acceptable)<o:p></o:p></h1> <h1> = (First, Middle Initial, Last) = = ; &n= bsp; = ; = &nb= sp; = (ski= p to part 5 if you list food stamp or tanf#)<= u><o:= p></o:p></h1> 1. &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; </span= ><o:p></o:p> 2. &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; </span= ><o:p></o:p> <![if !vml]><img width=3D534 height=3D140 src=3D"08-09lunchapp_files/image001.gif" alt=3D"ONE PER FAMILY" v:shapes=3D= "_x0000_s1032"><![endif]>3. = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &= nbsp; &nbs= p; <o:p></o:p> 4. &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; </span= ><o:p></o:p> 5. &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; </span= ><o:p></o:p> 6. &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; </span= ><o:p></o:p> 7. &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; </span= ><o:p></o:p> ----------------------------------------------------------------------= ---------------------------------------------------------------------------= -------------------<o:p></o:p> Part 2. If the child you are applying for is homeless, migrant, or a runaway che= ck the appropriate box and call 828-322-2855 extension 229 Homeless = ÿ<= /span> Migrant </= span>ÿ<= /span> </spa= n>Runaway = ÿ<o:p></o:p> -----------------------------------------------------------------------= ---------------------------------------------------------------------------= ---------------------------------------------------------------------------= --------------<o:p></o:p> <h2>Part 3. Foster Child (USE A SEPARATE APPLICATION FOR EACH FOSTER CHILD)= </h2> If this application is for a child who is the legal responsibility of a welfare agency or court, check this box <span style=3D'font-size:10.0pt; mso-bidi-font-size:12.0pt;font-family:Symbol;mso-ascii-font-family:"Times N= ew Roman"; mso-hansi-font-family:"Times New Roman";mso-char-type:symbol;mso-symbol-fon= t-family: Symbol'>= ÿ and then list the amou= nt of the child’s personal use monthly income: $ &= nbsp; &nbs= p; .___ per_______. Skip to par= t 5. <o:p></o:p> ----------------------------------------------------------------------= ---------------------------------------------------------------------------= -------------------<o:p></o:p> <h2>Part 4. Total Household Gross Income---If any child or adul= t in the household has no income, you MUST check the “No Income” Box in question 3 on= the application: if the box is not checked, the application will not <sp= an style=3D'font-weight:normal;mso-bidi-font-weight:bold'>be approved.<= /h2> <table class=3DMsoNormalTable border=3D1 cellspacing=3D0 cellpadding=3D0 style=3D'border-collapse:collapse;border:none;mso-border-alt:solid windowt= ext .5pt; mso-padding-alt:0in 5.4pt 0in 5.4pt;mso-border-insideh:.5pt solid windowte= xt; mso-border-insidev:.5pt solid windowtext'> <tr style=3D'mso-yfti-irow:0;mso-yfti-firstrow:yes;page-break-inside:avoid= '> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <![if !supportLists]>1. = <![endif]>Name <o:p></o:p></sp= an> (List everyone in<o:p></o:p></span= > household)<o:p></o:p></= p> </td> <td width=3D456 colspan=3D4 valign=3Dtop style=3D'width:4.75in;border:sol= id windowtext 1.0pt; border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt: solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> 2. Gross Income and how often received (Use exact income including cents.<sp= an style=3D'font-size:9.0pt'>) <o:p></o:p> Example: $100.15 per month, $100.97 twice a month, $100.76 every other week, $100 = per week<o:p></o:p> <table class=3DMsoNormalTable border=3D1 cellspacing=3D0 cellpadding=3D0 style=3D'border-collapse:collapse;border:none;mso-border-alt:solid windo= wtext .5pt; mso-padding-alt:0in 5.4pt 0in 5.4pt;mso-border-insideh:.5pt solid window= text; mso-border-insidev:.5pt solid windowtext'> <tr style=3D'mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:yes; height:26.5pt'> <td width=3D112 valign=3Dtop style=3D'width:84.35pt;border:solid window= text 1.0pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt; height:26.5pt'> Earnings from work before deductions<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border:solid windowt= ext 1.0pt; border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-a= lt: solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:26.5pt'> Welfare, child support, alimony<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border:solid windowt= ext 1.0pt; border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-a= lt: solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:26.5pt'> Pensions, retirement, Social Security<o:p></o:p> </td> <td width=3D202 valign=3Dtop style=3D'width:151.5pt;border:solid window= text 1.0pt; border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-a= lt: solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:26.5pt'> All Other Income<o:p></o:p> </td> </tr> </table> <o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border:solid windowtext= 1.0pt; border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt: solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> 3. Check if NO income<o:p>= </o:p> </td> </tr> <tr style=3D'mso-yfti-irow:1'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt'> Example:<o:p></o:p> Jane Smith<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $200.50 per week<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $100.75 per week<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $100.45 per month<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <span style=3D'font-size:16.0pt;mso-bidi-font-siz= e:12.0pt; font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi-font= -family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'><sp= an style=3D'mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ</span= ><o:p></o:p></= b> </td> </tr> <tr style=3D'mso-yfti-irow:2'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt'> <o:p> </o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <span style=3D'font-size:16.0pt;mso-bidi-font-siz= e:12.0pt; font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi-font= -family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'><sp= an style=3D'mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ</span= ><o:p></o:p></= b> </td> </tr> <tr style=3D'mso-yfti-irow:3'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt'> <o:p> </o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <span style=3D'font-size:16.0pt;mso-bidi-font-siz= e:12.0pt; font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi-font= -family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'><sp= an style=3D'mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ</span= ><o:p></o:p></= b> </td> </tr> <tr style=3D'mso-yfti-irow:4'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt'> <o:p> </o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <span style=3D'font-size:16.0pt;mso-bidi-font-siz= e:12.0pt; font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi-font= -family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'><sp= an style=3D'mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ</span= ><o:p></o:p></= b> </td> </tr> <tr style=3D'mso-yfti-irow:5'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt'> <o:p> </o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <span style=3D'font-size:16.0pt;mso-bidi-font-siz= e:12.0pt; font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi-font= -family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'><sp= an style=3D'mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ</span= ><o:p></o:p></= b> </td> </tr> <tr style=3D'mso-yfti-irow:6'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt'> <o:p> </o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <span style=3D'font-size:16.0pt;mso-bidi-font-siz= e:12.0pt; font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi-font= -family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'><sp= an style=3D'mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ</span= ><o:p></o:p></= b> </td> </tr> <tr style=3D'mso-yfti-irow:7'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt'> <o:p> </o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <span style=3D'font-size:16.0pt;mso-bidi-font-siz= e:12.0pt; font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi-font= -family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'><sp= an style=3D'mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ</span= ><o:p></o:p></= b> </td> </tr> <tr style=3D'mso-yfti-irow:8'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt'> <o:p> </o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per___<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> $____.__per__<o:p></o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt'> <span style=3D'font-size:16.0pt;mso-bidi-font-siz= e:12.0pt; font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi-font= -family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'><sp= an style=3D'mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ</span= ><o:p></o:p></= b> </td> </tr> <tr style=3D'mso-yfti-irow:9;mso-yfti-lastrow:yes;height:3.5pt'> <td width=3D187 valign=3Dtop style=3D'width:1.95in;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt;height:3.5pt'> &nbs= p; <o:p></o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:3= .5pt'> <o:p> </o:p> </td> <td width=3D120 valign=3Dtop style=3D'width:1.25in;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:3= .5pt'> <o:p> </o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:3= .5pt'> <o:p> </o:p> </td> <td width=3D108 valign=3Dtop style=3D'width:81.0pt;border-top:none;border= -left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1= .0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:3= .5pt'> <o:p> </o:p> </td> <td width=3D84 valign=3Dtop style=3D'width:63.0pt;border-top:none;border-= left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window= text .5pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:3= .5pt'> <o:p> </o:p> </td> </tr> </table> Part 5. Signature and Social Security Number (Ad= ult must sign)<o:p></o:p> An adult household member must sign the application.= If Part 4 is completed, the adult signing the form must also list his or her Social Security Number or Mark t= he “ I do not have a Social Security Number” box. (See Privacy Act Statement on the back of this page.) I certify (promise) that all information on this application is true and that= all income is reported. I understand that the school will get Federal funds bas= ed on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may = lose meal benefits, and I may be prosecuted. <o:p></o:p> Sign here: X_____________________________________ Print Name: ____________________________= _<o:p></o:p> Address: ______________________________________________Phone Number_______________________ Social Security Number: __ __ __- __ __-__ __ __ __ <span style=3D'font-size:11.0pt;mso-bidi= -font-size: 12.0pt;font-family:Symbol;mso-ascii-font-family:"Times New Roman";mso-hansi= -font-family: "Times New Roman";mso-char-type:symbol;mso-symbol-font-family:Symbol'>ÿ<= /span> I do not have a Social Security Number &nb= sp; Date _______________<o= :p></o:p> ----------------------------------------------------------------------= ---------------------------------------------------------------------------= -------------------<o:p></o:p> Part 6. Children’s racial and ethnic Identities (Optional)<o:p></o:p> Mark one or more racial identities: = ÿ Asian </s= pan>= ÿ White </s= pan>= ÿ Black= or African American </span= >= ÿ Ameri= can Indian or Alaska Native<o:p></o:p> = ÿ Native Hawaiian or Other Pacific Islander ÿ Other<o:p>= </o:p> Mark one ethnic Identi= ty: &= nbsp; &nbs= p; = ÿ Hispanic or Latino </sp= an>= ÿ Not Hispanic or Latino<o:p></o:p> <table class=3DMsoNormalTable border=3D1 cellspacing=3D0 cellpadding=3D0 wi= dth=3D832 style=3D'width:624.0pt;margin-left:-42.6pt;border-collapse:collapse;border= :none; mso-border-alt:solid windowtext .5pt;mso-padding-alt:0in 5.4pt 0in 5.4pt'> <tr style=3D'mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:yes; page-break-inside:avoid;height:71.5pt'> <td width=3D832 valign=3Dtop style=3D'width:624.0pt;border:solid windowte= xt 1.0pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:7= 1.5pt'> Don’t fill out this part.&n= bsp; This is for school use only.<o:p></o:p> Annual Income Conversion: Weekly = x 52, Every 2 Weeks x 26, Twice A Month x 24 Monthly x 12 <o:p></o:p> T &nbs= p; Total Income: ____________ Per: <span style=3D'font-size:8.= 0pt; font-family:Wingdings;mso-ascii-font-family:"Times New Roman";mso-hansi-f= ont-family: "Times New Roman";mso-bidi-font-family:Arial;mso-char-type:symbol;mso-sym= bol-font-family: Wingdings'>q Week, <span style=3D'font-size:8.0pt;font-family:Wingdings;mso-ascii-font-family:"Tim= es New Roman"; mso-hansi-font-family:"Times New Roman";mso-bidi-font-family:Arial; mso-char-type:symbol;mso-symbol-font-family:Wingdings'>q<= /span> Every 2 Weeks, </sp= an><span style=3D'font-size:8.0pt;font-family:Wingdings;mso-ascii-font-family:"Tim= es New Roman"; mso-hansi-font-family:"Times New Roman";mso-bidi-font-family:Arial; mso-char-type:symbol;mso-symbol-font-family:Wingdings'>q<= /span> Twice A Month, </sp= an><span style=3D'font-size:8.0pt;font-family:Wingdings;mso-ascii-font-family:"Tim= es New Roman"; mso-hansi-font-family:"Times New Roman";mso-bidi-font-family:Arial; mso-char-type:symbol;mso-symbol-font-family:Wingdings'>q<= /span> Month, <span style=3D'font-size:8.0pt;font-family:Wingdings;mso-ascii-font-family:"Tim= es New Roman"; mso-hansi-font-family:"Times New Roman";mso-bidi-font-family:Arial; mso-char-type:symbol;mso-symbol-font-family:Wingdings'>q<= /span> Year Household size: ________ <o:p></o:p> C &nbs= p; Categorical Eligibility: ___ Date Withdrawn: ________Eligibility: Free___ Reduced___ Denied___ Reason: _______________________<o:p></o:p> T &nbs= p; Temporary: Free_____ Reduced_____ Time Pe= riod: ___________ (expires after _____ days)<o:p></o:p> D &nbs= p; Determining Official’s Signature:___________________________= __________________ DDate: ______________<o:p></o:p> C &nbs= p; Confirming Official’s Signature: __________________ Date: _______ Follow-up Official’s Signature: __________________ Date: __= ____<o:p></o:p> </td> </tr> </table> <o:p> </o:p> </div> </body> 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