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St. Anne Catholic School

Somerset, WI

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Free & Reduced School Meals

2024-2025 St. Anne application For Free & Reduced School Meals
- This form is not accepting responses at this time.
  
  Complete one application per household. This program is designed to help ensure students have access to nutritious meals throughout the school day. If you believe your household may qualify, we encourage you to apply. The process is confidential and there are additional resource documents at the bottom of this form.
  
  Questions? Call the St. Anne Catholic School Office at 715-247-3762
  
  STEP 1: List ALL children, infants, and students up to and including grade 12.
  
  Number of Students REQUIRED Please fill out this field.
  
  Child 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field.
  
  Child 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field.
  
  Child 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field.
  
  Child 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field.
  
  Child 5
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field.
  
  Child 6
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field.
  
  Child 7
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field.
  
  Child 8
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field.
  
  STEP 2: Do any household members (including you) participate in: FoodShare (SNAP), W-2 Cash Benefits (TANF) or FDPIR? REQUIRED Yes No Please fill out this field.
  
  If yes, fill out the following two questions.
  
  Program Name Please enter valid data.
  
  Case Number Please enter valid data.
  
  What is the total size of your household? List # of people who live in your home. Please enter an integer (number).
  
  Step 3: Household Income REQUIRED Please fill out this field.
  
  Adult Household Member 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Earnings from Work REQUIRED Please fill out this field. Please enter an integer (number).
  
  How often received? REQUIRED Weekly Every 2 Weeks Monthly Annual Not Applicable Please fill out this field.
  
  Public Assistance, Child Support, Alimony $ Received REQUIRED Please fill out this field. Please enter an integer (number).
  
  How often received? REQUIRED Weekly Every 2 Weeks Monthly Not Applicable Please fill out this field.
  
  Pension, Retirement, Social Security, SSI, VA Benefits, All Other REQUIRED Please fill out this field. Please enter an integer (number).
  
  How often received? REQUIRED Weekly Every 2 Weeks Monthly Not Applicable Other Please fill out this field.
  
  You may be asked to provide your SSN to the office.
  
  Adult Household Member 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Earnings from Work REQUIRED Please fill out this field. Please enter an integer (number).
  
  How often received? REQUIRED Weekly Every 2 Weeks Monthly Annual Not Applicable Please fill out this field.
  
  Public Assistance, Child Support, Alimony $ Received REQUIRED Please fill out this field. Please enter an integer (number).
  
  How often received? REQUIRED Weekly Every 2 Weeks Monthly Not Applicable Please fill out this field.
  
  Pension, Retirement, Social Security, SSI, VA Benefits, All Other REQUIRED Please fill out this field. Please enter an integer (number).
  
  How often received? REQUIRED Weekly Every 2 Weeks Monthly Not Applicable Other Please fill out this field.
  
  You may be asked to provide your SSN to the office.
  
  Adult Household Member 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Earnings from Work REQUIRED Please fill out this field. Please enter an integer (number).
  
  How often received? REQUIRED Weekly Every 2 Weeks Monthly Annual Not Applicable Please fill out this field.
  
  Public Assistance, Child Support, Alimony $ Received REQUIRED Please fill out this field. Please enter an integer (number).
  
  How often received? REQUIRED Weekly Every 2 Weeks Monthly Not Applicable Please fill out this field.
  
  Pension, Retirement, Social Security, SSI, VA Benefits, All Other REQUIRED Please fill out this field. Please enter an integer (number).
  
  How often received? REQUIRED Weekly Every 2 Weeks Monthly Not Applicable Other Please fill out this field.
  
  You may be asked to provide your SSN to the office.
  
  Adult Household Member 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Earnings from Work REQUIRED Please fill out this field. Please enter an integer (number).
  
  How often received? REQUIRED Weekly Every 2 Weeks Monthly Annual Not Applicable Please fill out this field.
  
  Public Assistance, Child Support, Alimony $ Received REQUIRED Please fill out this field. Please enter an integer (number).
  
  How often received? REQUIRED Weekly Every 2 Weeks Monthly Not Applicable Please fill out this field.
  
  Pension, Retirement, Social Security, SSI, VA Benefits, All Other REQUIRED Please fill out this field. Please enter an integer (number).
  
  How often received? REQUIRED Weekly Every 2 Weeks Monthly Not Applicable Other Please fill out this field.
  
  You may be asked to provide your SSN to the office.
  
  Child Income: Sometimes children in the household earn or receive income. Please include the TOTAL income (before taxes and deductions) received by all children within the household listed in step 1 here REQUIRED Please fill out this field. Please enter an integer (number).
  
  STEP 4: Contact Information and adult signature.
  “I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that school ofcials may verify (confrm) the information. I am aware that if I purposely give false information, my children may lose meal benefts, and I may be prosecuted under applicable State and Federal laws.”
  
  I also agree and understand that by submitting my name in this section of the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Phone Number Maximum 20 characters Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Submit
  
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- Sources & Examples of Income
  
  Earnings from Work
  • Salary, wages, cash bonuses, tips, commissions
  • Net income from self-employment
  (farm or business)
  If you are in the U.S. Military:
  • Basic pay and cash bonuses (do NOT include
  combat pay, FSSA, or privatized housing
  allowances)
  • Allowances for of-base housing, food,
  and clothing
  Public Assistance/Alimony/
  Child Support
  • Unemployment benefts
  • Workers' compensation
  • Supplemental Security Income (SSI)
  • Cash assistance from State or local
  government
  • Alimony payments
  • Child support payments
  • Veterans benefts
  • Strike benefts
  Pensions/Retirement/
  All other sources of income
  • Social Security/Disability (including railroad
  retirement and black lung benefts)
  • Private Pensions or disability benefts
  • Income from trusts or estates
  • Annuities
  • Investment income
  • Earned interest
  • Rental income
  • Regular cash payments from
  outside household
  
  Examples of Income for Children
  • A child has a regular full or part-time job where they earn a salary or wages
  • A child is blind or disabled and receives Social Security benefits
  • A parent is disabled, retired, or deceased, and their child receives Social Security benefts
  • A friend or extended family member regularly gives a child spending money
  • A child receives regular income from a private pension fund, annuity, or trust
- Use of Information Statement
  
  The Richard B. Russell National School Lunch Act requires that we use information
  from this application to see who qualifes for free or reduced price meals. We can only
  approve complete forms. We may share your eligibility information with education, health,
  and nutrition programs to help them deliver program benefts to your household. Inspectors
  and law enforcement may also use your information to make sure that program rules are met.
  
  When asked within the school, please be sure to provide the last four numbers of the Social Security number of the adult household member who signs the application. If the adult does not have one, Applications for a foster child do not need to list a Social Security number. Applications for children in households receiving Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) or Food Distribution Program on Indian Reservations (FDPIR) do not need to list a Social Security number.
  Some children qualify for free meals without an application. Please contact your school to get
  free meals for a foster child, and children who are homeless, migrant, or runaway.
- Other Helpful Docs and disclosures
  
  This institution is an equal opportunity provider.
  Your information will be password protected on school drive to ensure all information entered is safe and only used for application purposes.

St. Anne Catholic School

140 Church Hill Road | Somerset, WI 54025 | Phone: 715-247-3762

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