Free School Lunch Eligibility Verification
Student Information
Student Name
Student ID
Date of Birth
School Name
Parent/Guardian Information
Parent/Guardian Name
Relationship to Student
Contact Number
Email Address
Home Address
Eligibility Information
Participation in Assistance Programs
SNAP
TANF
Medicaid
Other
None
Case Number (if applicable)
Number of people in household
Total household income (monthly)
Certification
I certify that all information provided is true and complete.
Signature
Date