Free and Reduced Lunch Application

Meeteetse Household Application for Free and Reduced School Meals
First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list all Household Members
Household Member

First NameLast Name
Is this member a student at Meeteetse School
Household Member

First NameLast Name
Is this member a student at Meeteetse School
Household Member

First NameLast Name
Is this member a student at Meeteetse School
Household Member

First NameLast Name
Is this member a student at Meeteetse School
Household Member

First NameLast Name
Is this member a student at Meeteetse School
Household Member

First NameLast Name
Is this member a student at Meeteetse School
Are any household members a Foster Child, Homeless, Migrant or Runaway?
Are any household members receiving Wyoming Family Assistance?
Please report All household income for a month. This includes Wages, Public Assistance, Alimony, Child Support, Pensions, Retirement and ALL other income.
If asked could you provide income verification?
Guidelines are based on 130% (free) and 185% (reduced) of the federal poverty guidelines.
Signature of Applicant:
Office use only
Determining Official's Signature: Date:

Confirming Official's Signature: Date:

Free

Reduced

Denied
Should be Empty:

Meeteetse Household Application for Free and Reduced School Meals