FIF Form 1

School Name (Nombre de Escuela):
Household Information (Informacion sobre el hogar)

List Names of all members of your household living with you. (Escriba los nombres de todas las personals que viven en su hogar.) You will also be asked to provide SNAP/TANF number of any member of your household where applicable.

All Household Member Names

Last Name, First Name, MI

Foster Child?

CPS Student?

Date of Birth

DHS Case Number

Member #1

Member #2

Member #3

Member #4

Member #5

Member #6

Homeless, Migrant, Runaway Child or child enrolled in Headstart (Nino sin Hogar, Emigrante, Fugitivo o Nino en el programa Head Start
Check all that apply:

Homeless Migrant Runaway Head Start
Homeless, Migrant, Runaway or Head Start Liaison Signature

Clear
Date (Fecha)

Month Day Year
Date
List Household Members WITH Income (SKIP THIS if you answered a SNAP/TANF number above or were any of the special choices)

Household Member Names with Income

Full Name

Gross Income

Frequency

Other Income

Frequency

Member #1

Member #2

Member #3

YES! I am interested in applying for a waiver of instructional fees. SI! Me aplicar por la exoneracion del pago de ensenanza.

YES! I am interested in applying for a waiver of instructional fees. SI! Me aplicar por la exoneracion del pago de ensenanza. YES! 1 am interested in applying for the Supplemental Nutrition Assistance (SNAP) and/or the Medicaid Program. SI! Me interesa aplicar para el Programa de Asistencia de Nutricion Suplementaria (SNAP) y/o la Medicaid. 773 553 5437
Signature (Firma):

Clear
Signature (Firma)
Signature of adult household member (Firma del miembro adulto del hogar)

Clear
Name

Parent Guardian First Name (Nombre del adulto del hogar) Parent Guardian Last Name (Apellido del adulto del hogar)
Date (Fecha)

Month Day Year
Date
Address (Direccion postal o de domicilio)
Zip Code (Codigo Postal)
Should be Empty:

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Household Information (Informacion sobre el hogar)