Income Survey
Please fill out this survey form to receive funding for your child's school by September 15, 2020.
Student (s) Name (s)
*
First Name
Last Name
Student (s) Name (s)
First Name
Last Name
Student (s) Name (s)
First Name
Last Name
Student (s) Name (s)
First Name
Last Name
HOUSEHOLD SIZE
*
1
2
3
4
5
6
7
8
MORE THAN 8 (See Office Personnel)
Is your family income less than the amount in column A (Free Eligibility) ?
Yes
No
Is your family income less than the amount in column B (Reduced Price Eligibility)?
Yes
No
Select your child(rens) grades. Hold down the CTRL key to select multiple grades
*
Nursery
Preschool
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Are any of your children eligible to receive medical assistance?
Yes
No
Are you receiving assistance under the Temporary Assistance to Needy Families (TANF) program?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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