Ohio Summer Food Service Program For Children
Income Eligibility Application For Camps and Enrolled Site
Dear Parent or Guardian:
Our organization serves nutritious free meals as part of the federally funded Summer Food Service
Program for Children (SFSP). Children are defined by the SFSP as being 18 years of age and under or
persons over 18 who are determined by a state or local public educational agency to be mentally or
physically disability. In order to be eligible for the SFSP, we must document the number of enrolled
children with household incomes less than or equal to the SFSP family size/income guidelines. With
your cooperation, we can qualify for federal reimbursement and keep costs to you at a minimum.
Please complete and return this form.
You are not required to answer this question. If you choose, please check one or more of the
following racial or ethnic identities:
In accordance with Federal Law and U.S. Department of Agriculture policy, This institution is prohibited from discriminating
on the basis of race, color, national origin, sex, age or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400
Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have
speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).
USDA is an equal opportunity provider and employer.
REDUCED INCOME ELIGIBILITY GUIDELINES – 185%
Guidelines to be effective from July 1, 2017 to June 30, 2018
Households with incomes less than or equal to the reduced price values below are eligible for free or reduced-price meal benefits.
||Twice Per Month Income
||Every Two Weeks Income
|For each additional family member, add
Please enter all pay periods and gross pay per income source.
(his income, her income, alimony received, child support received, pensions, retirement, welfare, social security, and any other source)
Privacy Act Statement:
Section 9 of the National School Lunch Act (NSLA) requires that, unless your child’s food stamp or OWF case number is provided, you must include the
social security number of the adult household member signing the application or indicate that the household member does not have a social security number. Provision of a
social security number is not mandatory, but if a social security number is not given or an indication is not made that the signer does not have such a number, the application
cannot be approved. This notice must be brought to the attention of the household member whose social security number is disclosed. The social security number may be
used to identify the household member in carrying out efforts to verify the correctness of information stated on the application or shared with other persons directly connected
with the administration or enforcement of the program under the NSLA or Child Nutrition Act of 1966 to determine program eligibility. These verification efforts may be carried
out through program reviews, audits, and investigations and may include contacting employers to determine income, contacting a food stamp or welfare office to determine
current certification for receipt of food stamps or OWF benefits, contacting the state employment security office to determine the amount of benefits received and checking the
documentation produced by household members to prove the amount of income received. These efforts may result in a loss or reduction of benefits, administrative claims or
legal action if incorrect information is reported.