AppendixA:
SupplementaryFormforproofofeligibilityforFreeSchoolMealsorPupil
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THIS APPLICATION MUST BE COMPLETED BY THE PERSON IN RECEIPT OF THE BENEFITS PLEASE WRITE CLEARLY IN BLOCK CAPITALS AND BLACK INK Your child may be able to receive free school meals if you are eligible for any of the
following (please tick the one you receive):
Benefits:
Income Support
Income-based Jobseekers Allowance
Income-related Employment and Support Allowance
Support under Part VI of the Immigration and Asylum Act 1999
The guaranteed element of State Pension Credit
Child Tax Credit (provided you’re not also entitled to Working Tax
Credit and have an annual gross income of no more than £16,190)
Working Tax Credit run-on - paid for 4 weeks after you stop
qualifying for Working Tax Credit
Universal Credit
Please tick
Children who receive any of the above benefits in their own right (ie they get benefits
payments directly, instead of through a parent or guardian) can also get free school meals.
Children under the compulsory school age who are in full time education may also be able to
receive free school meals.
You must provide evidence of eligibility for this benefit which is not less than three
months old. Failure to provide this evidence will mean that the application will be
invalid. Original documents must be provided by you and will be photocopied by the
school office and returned to you.
Parent /Carer/Guardian Details First names: Home Address Postcode Email Date of Birth Telephone No Mobile No National Insurance Number: Or NASS Reference Number (from Home Office letter e.g.06/06/01234/001) Relationship to the Child/Children: Mother Father Carer Guardian Details of child(ren) Pupil First name Surname Pupil 1 Pupil 2 Pupil 3 Pupil 4 Pupil 5 The information you have provided in this form will be used to check the FSM eligibility against a national database. I agree that you will use the information I have provided to process my claim for free school meals and will contact other sources as allowed by law to verify my initial, and ongoing, entitlement. Signed: Date: