MULTI-USE SCHOOL YEAR 2005–06 Exhibit IA

APPLICATION FOR FREE AND REDUCED-PRICE MEALS

To apply for free and reduced-price meals for your children, complete this application, sign your name and return the application to school. If your household receives benefits from Basic Food, TANF, or FDPIR, complete only Parts 1, 4, and 5. If your household does not receive benefits from Basic Food, TANF, or FDPIR, complete Parts 2a, 2b, 4, and 5. If you are applying for free and reduced-price meals for a foster child, complete parts 3, 4, and 5. For assistance please call your child's school and ask for help with the free and reduced-price meals application. Foster children need their own application.

PART 1 LIST CHILDREN ONLY OF BASIC FOOD, TANF, or FDPIR HOUSEHOLDS
Child's Name FIRST	MI	LAST	Basic Food or TANF (X)	FDPIR (X)	Case Number	School	Room	Grade

PART 2a IF YOU DON'T HAVE basic food, TANF, or FDPIR, LIST CHILDREN HERE
Child's Name FIRST	MI	LAST	School	Room	Grade	Date of Birth

PART 2b LIST HOUSEHOLD MEMBERS AND INCOME

Do not complete this section if you completed Part 1. List the names of EVERYONE living in your household, including yourself and any children listed in Part 2a. Write the amount of income (MONEY BEFORE DEDUCTIONS) each person now gets PER MONTH on the same line as his/her name and where it comes from, such as earnings, welfare, pensions, or other. If income is received other than monthly, use the income conversion chart provided below. Do not include foster children.

NAMES of Household Members			Gross MONTHLY Earnings (before deductions)		MONTHLY Welfare Payment, Child Support, Alimony	MONTHLY Payments from Pensions, Retirement, Social Security	Any Other MONTHLY Income
FIRST	MI	LAST	Job 1	Job 2
1.
2.
3.
4.
5.
6.					&nb