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The Grand Island Public School District will use the Alternate Income Eligibility Form to assess your eligibility for assistance with various required GIPS fees. This is because the USDA prohibits the use of the standard Free/Reduced Lunch application for schools and districts participating in the Community Eligibility Provision (CEP).
Return form to:
Grand Island Public Schools
Nutrition Services
123 S Webb Rd
PO Box 4904
Grand Island, NE 68802
If you have other questions or need help, call 308-385-5900
Below are instructions for the form's completion and purpose.For households with FOSTER, HOMELESS, MIGRANT or RUNAWAY CHILDREN, follow these instructions:If all children in the household are foster children:
- Part 1: List all foster children, the school they attend and their grade. Check the box indicating the child is a foster child.
- Part 2: Skip this part.
- Part 3: Complete this part. An adult must sign the form.
- Part 4: Sharing Information – for Ex: Band or scholarships
If some of the children in the household are foster children or are homeless, migrant or runaway children:
- Part 1: List all children, the school they attend and their grade. Check the appropriate box.
- Part 2: Follow these instructions to report total household income from last month.
- Column 1 – Household Members: List the first and last name of each person living in your household, related or not (such as grandparents, other relatives or friends) who share income and expenses. Attach another sheet of paper if necessary.
- Column 2 - Gross Income and How Often it was Received: Gross income is the amount earned before taxes and other deductions; it is not your take-home pay. For each household member, list each type of income received for the month. You must also report how often the money is received – weekly, every other week, twice a month, or monthly.
Earnings from Work includes the following:
- Salary, wages, cash bonuses
- Net income from self-employment (farm or business)
If you are in the U.S. Military, include:
- Basic pay and cash bonuses (do not include combat pay, Family Subsistence Supplemental Allowance (FSSA) payments or privatized housing allowances)
- Allowances for off-base housing, food and clothing
Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster care payments.
Public Assistance/Child Support/Alimony includes the following:
- Unemployment benefits, Worker’s compensation
- Supplemental Security Income (SSI), Cash assistance from state or local government
- Veteran’s benefits (VA benefits), Strike benefits
- Child support payments, Alimony payments
Pensions/Retirement/All Other Income includes the following:
- Social Security payments (including railroad retirement and black lung benefits)
- Private pensions or Disability benefits
- Regular income from trusts or estates, Annuities, Investment income, Earned interest, Rental income and Regular cash payments received from outside the household.
If you have no income, write “0” or leave the income field blank. By doing this, you are certifying there is no income to
report.
Household Size: Enter the total number of people in your household.
Social Security Number: The adult signing the form must list the last four digits of their Social Security Number (SSN) or check the box to the right labeled “Check if no SSN.”
Part 3: Complete this part. An adult must sign the form.
Part 4: Sharing Information – for Ex: Band or scholarships
Please note: Children who meet the definition of homeless, migrant or runaway, are eligible. However, the school district must
have documentation on file from a migrant coordinator, homeless/runaway liaison or the district’s Direct Certification list to
approved
For ALL other households, follow these instructions:
- Part 1: List all children, the school they attend and their grade.
- Part 2: Follow these instructions to report total household income from last month.
- Column 1 – Household Members: List the first and last name of each person living in your household, related or not (such as grandparents, other relatives or friends) who share income and expenses. Attach another sheet of paper if necessary.
- Column 2 - Gross Income and How Often it was Received: Gross income is the amount earned before taxes and other deductions; it is not your take-home pay. For each household member, list each type of income received for the month. You must also report how often the money is received – weekly, every other week, twice a month, or monthly.
Earnings from Work includes the following:
- Salary, wages, cash bonuses
- Net income from self-employment (farm or business)
If you are in the U.S. Military, include:
- Basic pay and cash bonuses (do not include combat pay, Family Subsistence Supplemental
- Allowance (FSSA) payments or privatized housing allowances)
- Allowances for off-base housing, food and clothing
Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster care payments.
Public Assistance/Child Support/Alimony includes the following:
- Unemployment benefits, Worker’s compensation
- Supplemental Security Income (SSI), Cash assistance from state or local government
- Veteran’s benefits (VA benefits), Strike benefits
- Child support payments, Alimony payments
Pensions/Retirement/All Other Income includes the following:
- Social Security payments (including railroad retirement and black lung benefits)
- Private pensions or Disability benefits
- Regular income from trusts or estates, Annuities, Investment income, Earned interest, Rental income and Regular cash payments received from outside the household.
If you have no income, write “0” or leave the income field blank. By doing this, you are certifying there is no income to
report.
Household Size: Enter the total number of people in your household.
Social Security Number: The adult signing the form must list the last four digits of their Social Security Number (SSN) or check the box to the right labeled “Check if no SSN.”
Part 3: Complete this part. An adult must sign the form.
Part 4: Sharing Information – for Ex: Band or scholarships
