Household Information Survey

Washtenaw Alliance for Virtual Education
Household Information Survey
To determine eligibility for various additional state and federal program benefits that your child(ren) may qualify for, please complete, sign and return this application to (school name

These sections must be completed by the head of household or designee.
PART A. SIZE OF FAMILY Enter the total number of individuals living in your household, including all adults and children
PART B. CURRENT BENEFITS - Complete below if applicable

If any member of your household receives Food Assistance Program (FAP), Family Independence Program (FIP), or FDPIR, provide the name and case number for the person who receives benefits. Bridge Card Numbers and Medicaid Numbers are NOT ACCEPTABLE case numbers.
Name:
Case Number:
PART C. STUDENT INFORMATION –
LAST NAME
FIRST NAME
DATE OF BIRTH
NAME OF SCHOOL
IS THE STUDENT CURRENTLY HOMELESS?
CURRENT MONTHY INCOME
Do you receive any of the following:
Do you receive monthly payments from any of the following:
Do you receive any monthly Dividends or Interest on Savings
Do you receive any Worker's Comp, Unemployment, or Strike Benefits
Do you receive benefits for any of the following:
Last 4 digits of Parent/Guardian's social security number (DO NOT PUT THE WHOLE NUMBER)
Date:
Print Name:
Sign Here:
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Work Phone
Email Address
example@example.com
Should be Empty: