SP 33-2015A3: Revised Prototype Free and Reduced Price Application Word Version

Household Determination: Convert to Annual if Multiple Signature of  Foster Frequencies: Confirming Official: Student(s):______Weekly x52, Every 2 Weeks x26, *Must be a different individual than the Determining Official ______Twice Monthly x24, Monthly x12 Date 1st Date 2nd  Food Stamp/TAFI/FDPIR Notification Sent: Notification Sent:  Income: Total Income $______Frequency______# in Household______Approved: Denied: Date Notice Sent: Results:  Free Meals  Income over Allowed  No Change  Free to Reduced  Reduced to Free  Reduced-Price Meals  Incomplete/Missing  Ineligible – Reason: ______Withdrawal Date:______ Other ______Signature of Date Determined: Signature of Date: Determining Official: Verifying Official: *Must be a different individual than the *Can be same as Determining Official Confirming Official