2022-2023 TARHEEL CHALLENGE ACADEMY

Free and Reduced Price School Meals Household Application

(Complete one application per household.) When completed, click the submit button and your free and reduced meal application will be sent to the appropriate academy.

A. CHILDREN and STUDENT Household Members

1) List the names of all INFANTS, CHILDREN and STUDENTS in the household including grade 12.

2) Student status choose "S" for STUDENT or "O" for other children that are not students to indicate the child's role in the household.

Academy Attending *

First, Middle Initial, Last (TCA Candidate) *

Status *

School Name (Please enter TCA for your child attending the academy) *

Grade *

If applicable, please choose if a child/student is:

CHILD/STUDENT INCOME - EARNINGS FROM WORK

ENTER total GROSS income amount
(before deductions) in whole dollars
only ($000)

Choose Frequency of Payment

CHILD/STUDENT INCOME
from
ALL OTHER Sources

Choose Frequency of Payment

First, Middle Initial, Last (Child #2)

Status

School Name

Grade

If applicable, please choose if a child/student is:

CHILD/STUDENT INCOME - EARNINGS FROM WORK

ENTER total GROSS income amount
(before deductions) in whole dollars
only ($000)

Choose Frequency of Payment

CHILD/STUDENT INCOME
from
ALL OTHER Sources

Choose Frequency of Payment

First, Middle Initial, Last (Child #3)

Status

School Name

Grade

If applicable, please choose if a child/student is:

CHILD/STUDENT INCOME - EARNINGS FROM WORK

ENTER total GROSS income amount
(before deductions) in whole dollars
only ($000)

Choose Frequency of Payment

CHILD/STUDENT INCOME
from
ALL OTHER Sources

Choose Frequency of Payment

First, Middle Initial, Last (Child #4)

Status

School Name

Grade

If applicable, please choose if a child/student is:

CHILD/STUDENT INCOME - EARNINGS FROM WORK

ENTER total GROSS income amount
(before deductions) in whole dollars
only ($000)

Choose Frequency of Payment

CHILD/STUDENT INCOME
from
ALL OTHER Sources

Choose Frequency of Payment

First, Middle Initial, Last (Child #5)

Status

School Name

Grade

If applicable, please choose if a child/student is:

CHILD/STUDENT INCOME - EARNINGS FROM WORK

ENTER total GROSS income amount
(before deductions) in whole dollars
only ($000)

Choose Frequency of Payment

CHILD/STUDENT INCOME
from
ALL OTHER Sources

Choose Frequency of Payment

B. Assistance Programs

Do any household members (including you)
currently participate in one or more of the
following assistance programs:
FNS, WorkFirst/TANF or FDPIR? *

No

Yes

If "YES" please provide a
case number (only one.)
If "NO" please enter N/A *

If you answered yes and supplied

a case #, SKIP to SECTION E

C. ADULT Household Members

LIST ALL ADULT household members

(FIRST and LAST name) even if they

do not receive income.

Head
of
Household

GROSS Income
Earnings from
WORK

Choose
Payroll
Frequency

Public Assistance/
Alimony/
Child Support

Choose
Payment
Frequency

Pensions/
Retirement/
All Other Income

Choose
Payment
Frequency

Other
Household
Adult

GROSS Income
Earnings from
WORK

Choose
Payroll
Frequency

Public Assistance/
Alimony/
Child Support

Choose
Payment
Frequency

Pensions/
Retirement/
All Other Income

Choose
Payment
Frequency

Other
Household
Adult

GROSS Income
Earnings from
WORK

Choose
Payroll
Frequency

Public Assistance/
Alimony/
Child Support

Choose
Payment
Frequency

Pensions/
Retirement/
All Other Income

Choose
Payment
Frequency

Other
Household
Adult

GROSS Income
Earnings from
WORK

Choose
Payroll
Frequency

Public Assistance/
Alimony/
Child Support

Choose
Payment
Frequency

Pensions/
Retirement/
All Other Income

Choose
Payment
Frequency

Other
Household
Adult

GROSS Income
Earnings from
WORK

Choose
Payroll
Frequency

Public Assistance/
Alimony/
Child Support

Choose
Payment
Frequency

Pensions/
Retirement/
All Other Income

Choose
Payment
Frequency

D. Household Total and Social Security Number (SSN)

Enter Total Number of Household Members (Children and Adults) HERE

ENTER LAST FOUR DIGITS OF SSN HERE
(Head of Household or Primary Wage
Earner Only)

I do not have a Social Security Number

Check if true

E. Attestation

An adult household member must complete this application. "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 officials may verify (check) the information. I am aware that if I purposely give false information, my child(ren) may lose meal benefits and I may be prosecuted under State and Federal laws."

Head of Household Signature - Your typed name constitutes your signature *

Today's Date * +

Email Address:

Street Address *

City *

State *

Zip Code *

Contact Number *

F. Child(ren)'s Ethnic and Racial Identities (Optional)

SELECT one ethnicity

Hispanic or Latino

Not Hispanic or Latino

SELECT one or more (regardless of ethnicity)

For Office Use Only

Total Household Members _____ Total Household Income __________ Per ______

Income Conversion

Note: If there are multiple income sources with more than on frequency, the SFA must annualize all income by multiplying:

Weekly (x52) Biweekly (x26) Monthly (x12) Bimonthly (x24) Annually

Eligibility Determination:

Categorical Eligibility

Free

Reduced

Denied

Determining Official's Signature and Date

_______________________________________

Confirming Official's Signature and Date

_______________________________________

Verifying Official's Signature and Date

_______________________________________