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JLB-FRM1 - Electronic Version

 

JLB-FRM1 

Hopkinton Public Schools 
89 Hayden Rowe Street Hopkinton, MA. 01748 

Dear Parent(s) or Guardian(s): 

Applicants should read JLB-PRC1 Financial Assistance Program (available on the district webpage) to thoroughly familiarize themselves with the Financial Assistance Program requirements before completing this application. 

The application covers a one-year period and you may apply for financial assistance at any time. The application period for the 2019-2020 school year is open as of April 2, 2019. 

Documentation of income is required to determine eligibility and level of assistance. The documentation of household income includes, but is not limited to the following: 

• 2018 IRS Form 1040, Pages 1 and 2 of all adults residing in the household; 

• Supplemental Security Income (SSI) and Disability Income; 

• Unemployment Compensation and severance pay; 

• Alimony and child support agreements; 

• Transitional Assistance Letters and Benefits; and 

• Pay stubs if there has been a decline in income from the previous tax year. 

Definition of Income: 

In accordance with the Department of Agriculture’s policy as provided in the Food and Nutrition Service publication Eligibility Manual for School Meals, “income”, means income before any deductions such as income taxes, Social Security Taxes, insurance premiums, charitable contributions, and bonds. It includes the following: (1) monetary compensation for services, including wages, salary, commissions or fees; (2 )net income from nonfarm self-employment; 

(3) net income from farm self-employment; (4) Social Security; (5) dividends or interest on savings or bonds or income from estates or trusts; (6) net rental income; (7) public assistance or welfare payments; (8) unemployment compensation; (9) government civilian employee or military retirement, or pensions or veterans payments; (10) private pensions or annuities; (11) alimony or child support payments; (12) regular contributions from persons not living in the household; (13) net royalties; and (14) other cash income. Other cash income would include cash amounts received or withdrawn from any source including savings, investments, trust accounts and other resources that would be available to pay the price of a child’s meal. 

The following form must be completed to apply for assistance. The completed application and required documentation of income supporting your child(ren) are necessary in order to make an eligibility determination. Incomplete applications will be returned. 

Copies of documentation of income supporting your children can be made at the Business Office at no charge to you if you submit your application in person. If mailed, documents will not be copied and returned to you. 

If you have any questions regarding the application process, please contact Mary Ann Fitzpatrick, Financial Assistance Coordinator, at (508) 417-9381. Once a determination of eligibility has been made, you will be notified of that decision by letter. Please allow two (2) weeks for processing.

Financial Assistance Application 

Please provide the following confidential information in its entirety. 

Parent/Guardian Last Name	Parent/Guardian First Name	Home Phone	Home Address
Other Parent/Guardian Last Name	Other Parent/Guardian First Name	Home Phone	Home Address

 

List everyone who lives in your household—both children and adults—including yourself. 

 

Last Name	First Name	Relationship to You

 

Total number of members residing in your household 

Number of dependents claimed on Federal tax filing (line 6d) 

OR Circle: 

I did not file a tax return 

List only students for whom you are requesting fee assistance. If attaching additional names, check here:  

Last Name	First Name	Relationship to You	2019/2020 School	2019/2020 Grade

 

Failure to provide proof of all household members with income will result in a delay in processing this application. 

REQUIRED DOCUMENTATION (AS APPLICABLE)	CHECK IF  INCLUDE  D	CHECK IF  NOT  APPICABLE	IF APPLICABLE, BUT DOCUMENTATION IS NOT PROVIDED, STATE REASON (attach explanation if necessary)
2018 IRS Tax Return Transcript; call IRS at 1800-908-9946 or visit:  https://www.irs.gov/Individuals/Get-Transript OR signed copy of 2018 Federal Tax Return
Supplemental Social Security (SSI) Disability and/or Death Benefit letter documenting benefit(s) dated 2019.
Unemployment Compensation and Severance Pay
Alimony & Child Support Agreements
Transitional Assistance Letter dated in 2019 for SNAP (Food Stamps) or TANF Benefits: to request a recent copy call: 508-661-6600
Documentation for FOSTER Child (Foster Children are handled as one household and are not included as a member of the family in which they are residing or in the household income of the custodial parent.)
Non-custodial parent income is considered when one parent receives the tax deduction for the dependent and there is no record of child support. Provide all that are applicable as listed herein.
Unearned income, gifts, donations, family support (e.g. rent free housing, money, etc.) from outside of the domicile must be reported as financial support.

 

Do not send originals; they cannot be returned. Copies can be made for you in person at the Hopkinton Public Schools’ Business Office. All documentation is treated confidentially and details are not shared with other offices or departments. All documents are shredded and destroyed after three (3) years. 

I certify (promise) that all information and documentation provided with this application is true and that all income sources have been listed. I understand that school officials may verify (check) the information provided and that if I purposely failed to provide all sources of income or have provided false information, my child(ren) may lose benefits. 

Signed:

Print Name:

 Date: 

Mail completed form to: Hopkinton Public Schools Administration, Financial Assistance, 89 Hayden Rowe Street, Hopkinton, MA 01748