Dear Parent/Guardian:

Schools receive certain federal and state funding (learning assistance programs, teacher incentives, etc based on the number of children from households that are at or below the federal poverty level. This Family Income Survey provides your child's school a way to collect household income information. This information makes sure your child's school receives the full amount of federal and state funding and makes sure your child receives services they are entitled to when free/reduced price applications are not collected. This is not a meal application.

1. DO I NEED TO FILL OUT A FORM FOR EACH CHILD? YES. Please fill out this information for each of your NVLA students.

2. WHY SHOULD I COMPLETE THIS FORM? Many State and Federal programs use household income information to determine eligibility for their programs. By completing this form your school is able to determine eligibility for additional programs your child(ren) may qualify for.

3. WHO SHOULD I INCLUDE AS MEMBERS OF MY HOUSEHOLD? You must include all people living in your household, related or not (such as grandparents, other relatives, or friends) who share income and expenses. You must include yourself and all children living with you. If you live with other people who are economically independent (for example, people who you do not support, who do not share income with you or your children, and who pay a pro-rated share of expenses), do not include them.

4. WHAT IF MY INCOME IS NOT ALWAYS THE SAME? List the amount that you normally receive. For example, if you normally make $1000 each month, but you missed some work last month and only made $900, put down that you made $1000 per month. If you normally get overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income.

5. WHAT IS INCLUDED IN "HOUSEHOLD INCOME"? Annual Household Income includes the following:

• Gross earnings from work: Use your gross income, not your take-home pay. Gross income is the amount earned before taxes and other deductions. This information can be found on your pay stub or if you are unsure, your supervisor can provide this information. Net income should only be reported for self-owned business, farm, or rental income.

• Welfare, Child Support, Alimony: Include the amount each person living in your household receives from these sources.

• Pensions, Retirement, Social Security, Supplemental Security Income (SSI), Veteran's benefits (VA benefits), and disability benefits: Include the amount each person living in your household receives from these sources.

• All Other Income: Include worker's compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income received. Do not include income from WIC, federal education benefits and foster payments received by your household.

• Military Housing Allowances and Combat Pay: Include off-base housing allowances. Do not include Military Privatized Housing Initiative or combat pay.

• Overtime Pay: Include overtime pay ONLY if you receive it on a regular basis.

Part 3. If a case number in Part 2 is not provided, then please indicate the following:

Report Annual Income for Total Household
(include ALL adults and ALL child income)

Part 4. CONTACT INFORMATION AND ADULT SIGNATURE: I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get state and federal funds based on the information I give. I understand that school officials may verify (check) this information. I understand if I purposely give false information that I may be prosecuted. I understand my child's poverty status may be shared with other programs/agencies as allowed by law.