Title I Non-Public Family Income Survey

JEFFERSON PARISH SCHOOLS

Local Education Agency
Non Public/Private School
TYPE IN NAME OF SCHOOL
Title I Non-Public Family Income Survey
The information gathered from this survey will help determine our school’s eligibility for participation in Title I, Part A services for extra academic support for the 2020 – 2021 school year. The information requested below is confidential. You do not have to list student or family names.

Please complete and return this survey to the principal’s/administrator’s office the next school day. Thank you for participating and supporting our school.

1. Please complete one survey form for each child in your family who attends our school. We only need the student’s home address and grade level in order to apply for services.
Address

Street Number and Name (Address)

Street Address Line 2

City, State and Zip CodeState / Province

Postal / Zip Code
Student's Current Grade Level
2. In the first column below, choose the total number of persons living at the household address listed above.

3. On the same row as the number you chose in the first column, answer the question regarding household income by selecting “yes” or “no”.

How many people (adults and children) reside in your home? (Select only one)*

	ANNUAL HOUSEHOLD INCOME
2 People Is your household income less than $31,895?
3 People Is your household income less than $40,183?
4 People Is the total household income less than $48,471?
5 People Is the total household income less than $56,759?
6 Peole Is the total household income less than $65,045?
7 People Is the total household income less than $73,335?
8 People Is the total household income less than $81,623?
9 People Is the total household income less than $89,911?
10 People Is the total household income less than $98,198?

Check all items below that apply to this student.

	Check all that apply
Was in Head Start in the past 2 years
Is Homeless
Is in Foster Care