OKINAWA FREE AND REDUCED PRICE SCHOOL MEALS PROGR AM (Form OSTO-25) 

PRIVACY ACT STATEMENT 
AUTHORITY: 10 U.S.C. 8013. 
PURPOSE:  To enter information from sponsor and dependents and to determine eligibility for free or reduced lunch program. 
ROUTINE USES: None. 
DISCLOSURE: Voluntary. Failure to provide information may delay or prevent eligibility.  

1. SPONSOR’S INFORMATION  
NAME (Last, First MI)  
RANK
SSN  
UNIT
BASE
DUTY PHONE  
MAILING ADDRESS
HOME PHONE  

2. STUDENT INFORMATION: PRINT each child’s name, school and grade.  
LAST NAME OF STUDENT
FIRST NAME OF STUDENT
SCHOOL
GRADE  

3. HOUSEHOLD MEMBERS and MONTHLY INCOME Enter last months gross monthly  
List first and last name of all family members 
not listed in Part 2  					SPONSOR  

Basic Pay / Salary  
BAS, Special and incentive pay or differential  
Income from self-employment  
Social security payments  
Dividends or interest  
Income from estates or trusts  
Rental income  
Public assistance or welfare payments  
Government retirement or pensions  
Veterans' payments(except educational)  
Private pensions or annuities  
Alimony or child support  
Regular contributions from persons not living in the household  
Other income  
TOTAL  

4. Signature and Social Security Number (Adult must sign)  
• I certify the information on this form is true and accurate and that all household income is reported. I understand that I must report any decrease in household members or increase of household income in excess of $50 per month or $600 per year. 

• Section 9 of the National School Lunch Act, as amended, requires that in order for your child to be eligible for free or reduced-price meals, you must provide 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. If a social security number is not provided, the application cannot be approved. 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. 

• Income verification efforts may be carried out through program reviews, audits, and investigations and may include contacting employers to determine income 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. 

Signature: _____________________________________________ SSN: ____________________________  

STO USE ONLY  
Household Size: _________ Total Annual Household Income: ________________________ 
Eligibility: __Free __Reduced __Denied, Reason: 
Approving Official Signature: ___________________________________ Date: ______________________