<p> APPLICATION FORM FOR FREE SCHOOL MEALS</p><p>To receive Free School Meals you must be receiving:</p><p>Income Support Income-based Jobseeker’s Allowance Income-related employment and support allowance (ESA IR) Support under part VI of the Immigration and Asylum Act 1999 Child Tax Credit (provided you are not entitled to Working Tax Credit and whose annual income (as assessed by the Revenue and Customs) does not exceed £16,190 Guarantee element of State Pension Credit </p><p>How to apply:</p><p>1) To make a telephone application call 01708 433929. Immediate eligibility confirmation given using the Free School Meals Eligibility Checking Service and early start date for Free School Meals. or 2) Complete this application form and sign the declaration and agreement. </p><p>3) The Free School Meals Officer will contact you if there are any queries about your eligibility and to confirm the Free School Meals start date.</p><p>4) Return form to: Student Finance, London Borough of Havering, Public Advice and Service Centre (PASC), The Liberty Centre, Romford, RM1 3RL</p><p>You can call in at the PASC between 9.00am & 4.45pm Mon-Fri or Telephone: 01708 433929/53 or Email: [email protected]. Visit our website at: www.havering.gov.uk</p><p>Personal details of benefit claimant: 1. Last name Mr/Mrs/Miss/Ms/Other</p><p>2. First name(s)</p><p>3. Date of birth</p><p>4. National Insurance No.</p><p>5. Relationship to pupil</p><p>6. Address</p><p>Postcode</p><p>7. Telephone Number(s)</p><p>Please list below the names of each child you are claiming for:</p><p>Last name First name Date of birth School</p><p>Declaration: I understand that the information I give on this form may be used by Local Authorities for the prevention and detection of fraud and that if I knowingly or neglectfully provide false information, entitlement to Free School Meals may be lost and I may face prosecution. The information I have given on this form is complete and accurate to the best of my knowledge and belief. I will contact the Local Authority if my circumstances change in anyway that may effect my entitlement to Free School Meals for the child(ren) I have named.</p><p>Agreement: I agree to the Free School Meals Officers using the Free School Meals Eligibility Checking Service to confirm my eligibility for Free School Meals for this application and for checking my continued eligibility. </p><p>Signature of claimant……………………………………………Date………………</p><p>For Office Use only: Checking Service Found: Yes / No Paper Proof Yes / No Date: ______Officers Sig:______School Rang: Yes / No Start Date: </p>