California Department of Education
School Year 2023-2024
Dear Parent or Guardian:
The Pleasant Valley School District participates in the National School Lunch Program and/or School Breakfast Program by offering nutritious meals every school day. All PVSD students will receive nutritious meals free of charge every school day. The meal programs we participate in are supported by federal and state reimbursements. You or your children do not have to be U.S. citizens to qualify for free meals.
No qualifications are necessary for the 23-24 SY.
Why fill out School Benefit form? Why
APPLYING FOR BENEFITS
An application for free or reduced-price meals cannot be reviewed unless all required fields are completed. A household may apply at any time during the school year. If you are not eligible now, but your household income decreases, household size increases, or a household member becomes eligible for CalFresh, California Work Opportunity and Responsibility to Kids (CalWORKs), or Food Distribution Program on Indian Reservations (FDPIR) benefits, you may submit an application at that time.
An application is not required if the household receives a notification letter indicating all children are automatically certified for free meals. If you did not receive a letter, please complete a School Benefit Form.
School officials may verify the information on the application at any time during the school year. You may be asked to submit information to validate your income or current eligibility for CalFresh, CalWORKs, or FDPIR benefits.
Households that receive Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) benefits, may be eligible for additional benefits by completing a form.
HOMELESS, MIGRANT, RUNAWAY, AND HEAD START
Children who meet the definition of homeless, migrant, or runaway, and children participating in their school’s Head Start program are eligible for free meals. Please contact Carol Bjordahl for assistance at 805-389-2100.
The legal responsibility must be through a foster care agency or court to qualify for benefits. A foster child may be included as a household member if the foster family chooses to apply for their non-foster children on the same application and must report any personal income earned by the foster child. If the non-foster children are not eligible, this does not prevent a foster child from receiving benefits.
If you do not agree with the school's decision regarding your application’s determination or the result of verification, you may discuss it with the hearing official. You also have the right to a fair hearing, which may be requested by calling or writing to the following: Chris Johnston, PVSD, 600 Temple Ave, Camarillo, CA 93010, 805-389-2100.
Your child’s eligibility status from the previous school year will continue into the new school year for up to 30 operating days or until a new determination is made. When the carryover period ends, and you feel your household may be entitled to additional benefits, you must complete a 23/24 School Benefit Form here . School officials are not required to send a reminder or expired eligibility notices.
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.), should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing, or have speech disabilities may contact USDA through the Federal Relay Service at 800-877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call 866-632-9992. Submit your completed form or letter to the USDA by (1) Mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue SW, Washington, D.C. 20250-9410; (2) Fax: 202-690-7442; or (3) Email: email@example.com.
HOW TO APPLY FOR SCHOOL BENEFITS
Complete one form per household. Please print clearly with a pen. Incomplete, illegible, or incorrect information will delay processing.
- APPLICANT INFORMATION– Complete the entire section in STEP 1 including the last 4 digits of your Social Security Number. If the applicant does not have a Social Security Number, check the box marked “NONE”.
- ASSISTANCE PROGRAMS–If any household member (child or adult) participates in CalFresh, CalWORKs, or FDPIR, then all children are eligible for free meals. An applicable case number must be entered. Continue to STEP 3, skip STEP 4 and continue to STEP 5.
- STUDENT INFORMATION– Include all students who reside in the household. Print school name, student name (last, first, middle initial), date of birth, and grade level. If any student listed is a foster child, circle yes/no. If you are only applying for a foster child, complete STEP 3, and then continue to STEP 5. If any student listed may be homeless, migrant, or runaway, circle yes/no Homeless, Migrant, or Runaway and complete all STEPS of the application.
- REPORT INCOME FOR ALL HOUSEHOLD MEMBERS– Applicant must report gross income (before deductions) from all household members (children and adults) in whole dollars. Enter 0 for any household member that does not receive income.
Print the names (first and last) of all other household members not listed in STEP 3, including yourself. Report the total gross income from each source and enter the appropriate pay period.
- CONTACT INFORMATION AND ADULT SIGNATURE–The form must be signed by an adult household member including contact information, and today’s date.
OPTIONAL- CHILDREN’S ETHNIC AND RACIAL IDENTITIES
This field is optional to complete and does not affect your children’s eligibility for free or reduced-price meals. Please check the appropriate boxes.
The Richard B. Russell National School Lunch Act requires information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced-price meals. You must include the last four digits of the SSN of the adult household member who signs the application. The last four digits of the SSN are not required when you list a CalFresh, CalWORKs, or FDPIR case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have an SSN by selecting the checkbox. We will use your information to determine if your child is eligible for free or reduced-price meals, and for administration and enforcement of the lunch and breakfast programs.
QUESTIONS OR ASSISTANCE
Please contact Leslie Tuimaualuga at 805-389-2100 x1223.
Please submit a complete School Benefit Form to your child’s school or the Food Services office at 600 Temple Avenue, Camarillo, CA 93010. You will be notified if your application is approved or denied.
PVSD is an equal-opportunity provider.