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This notice qualifies your child(ren) for SM FREE MEALS OR FREE MILK at School or Child Care Center or Head Start Program Name: Case number: Date: Address: Case worker signature City, state, ZIP: Names of children certified Birthdate School or child care Grade Take this notice to your child’s school or child care/Head Start Program For your child to receive free meals at school: • Check with your child’s school to determine if they participate in the National School Lunch Program (NSLP) and School Breakfast Program (SBP). • No other application is needed if your child receives Supplemental Nutrition Assistance Program (SNAP) and/or Temporary Assistance for Needy Families (TANF). For your child to receive free milk at school: • Check with your child’s school to determine if they participate in the Special Milk Program. If your child care provider or Head Start Program asks you to complete a Child and Adult Care Food Program (CACFP) Confidential Income Statement: • Write in the name of the day care or Head Start Program for each child listed above. • No other application is needed for your child to receive free meals. Pregnant or breast-feeding women in your household or children under age 5 may qualify for benefits in the Women, Infants and Children (WIC) Program. Oregon SafeNet can help you find free or low-cost healthcare and other important services in your community. Call 1-800-SafeNet (1-800-723-3638), Monday–Friday, 8:00 am–6:00 pm. This document can be provided upon request in an alternate format for individuals with disabilities or in a language other than English for people with limited English skills. To request this publication in another format or language, contact the Publications and Design Section at 503-378-3486, 711 for TTY, or email [email protected]. To file a complaint of discrimination, write the United States Department of Agriculture (USDA), Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call, toll free 866-632-9992 (Voice). TDD users can contact USDA through local relay or the Federal relay at 800-877-8339 (TDD) or 866-377-8642 (relay voice users). USDA and the State of Oregon are equal opportunity providers. School use only Date benefits begin: ______________ Date benefits no longer received: _______________ DHS 0857 (6/13).