If your household receives benefits from [alabama SNAP], or [state TANF] [or the Food distribution program on indian reservations (FDPIR)], follow these instructions:

Part 1: List all household members and the name of school for each child.

Part 2: List the case number for any household member (including adults) receiving [ALABAMA SNAP] or [State TANF] or [FDPIR] benefits.

Part 3: Skip this part.

Part 4: Skip this part.

Part 5: Sign the form. The last four digits of a Social Security Number are not necessary.

Part 6: Answer this question if you choose to.

if no one in your household gets [ALABAMA SNAP] or [ALABAMA TANF] benefits and if any child in your household is homeless, a migrant or runaway, follow these instructions:

Part 1: List all household members and the name of school for each child.

Part 2: Skip this part.

Part 3: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call Anissa Ball, Parent Involvement Coordinator at 205-367-8195 or e-mail balla@pickens.k12.al.us.

Part 4: Complete only if a child in your household isn’t eligible under Part 3. See instructions for All Other Households.

Part 5: Sign the form. The last four digits of a Social Security Number are not necessary if you didn’t need to fill in Part 4.

Part 6: Answer this question if you choose to.

If you are applying for a FOSTER CHILD, follow these instructions:

If all children in the household are foster children:

Part 1: List all foster children and the school name for each child. Check the box indicating the child is a foster child.

Part 2: Skip this part.

Part 3: Skip this part.

Part 4: Skip this part.

Part 5: Sign the form. The last four digits of a Social Security Number are not necessary.

Part 6: Answer this question if you choose to.

If some of the children in the household are foster children:

Part 1: List all household members and the name of school for each child. For any person, including children, with no income, you must check the “No Income” box. Check the box if the child is a foster child.

Part 2: If the household does not have a case number, skip this part.

Part 4: Follow these instructions to report total household income from this month or last month.

· Box 1–Name: List all household members with income.

· Box 2 –Gross Income and How Often It Was Received: For each household member, list each type of income received for the month. You must tell us how often the money is received—weekly, every other week, twice a month or monthly. For earnings, be sure to list the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. For other income, list the amount each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), and disability benefits. Under All Other Income, list Worker’s Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income. Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster payments received by the family from the placing agency. For ONLY the self-employed, under Earnings from Work, report income after expenses. This is for your business, farm, or rental property. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income.

Part 5: Adult household member must sign the form and list the last four digits of their Social Security Number (or mark the box if s/he doesn’t have one).

Part 6: Answer this question, if you choose.

ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:

Part 1: List all household members and the name of school for each child. For any person, including children, with no income, you must check the “No Income” box.

Part 2: If the household does not have a case number, skip this part.

Part 4: Follow these instructions to report total household income from this month or last month.

· Box 1–Name: List all household members with income.

· Box 2 –Gross Income and How Often It Was Received: For each household member, list each type of income received for the month. You must tell us how often the money is received—weekly, every other week, twice a month or monthly. For earnings, be sure to list the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. For other income, list the amount each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), and disability benefits. Under All Other Income, list Worker’s Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income. Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster payments received by the family from the placing agency. For ONLY the self-employed, under Earnings from Work, report income after expenses. This is for your business, farm, or rental property. Do not include income from SNAP, FDPIR, WIC or Federal education benefits. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income.

Part 5: Adult household member must sign the form and list the last four digits of their Social Security Number (or mark the box if s/he doesn’t have one).

Part 6: Answer, this question if you choose.