HOUSEHOLD INFORMATION REPORT SY 2020 - 2021

This survey is used to determine eligibility for state benefits for which your child(ren)'s school may qualify. Please complete, sign, and return this form to your child's school.

If any member of your household receives benefits from the Food Assistance Program (FAP), Family Independence Program (FIP), or FDPIR, please follow these instructions:

Part A: Student Information – For each student in the household Pre-K through 12th grade, list the last name, first name, grade level, school, and H if homeless, M if Migrant, R if Runaway or F if a Foster Child.

Part B: Benefits Received – If any household member, including adults, receives Food Assistance Program (FAP), Family Independence Program (FIP), or Food Distribution Program on Indian Reservations(FDPIR), provide the name and case number.Bridge Card Numbers and Medicaid Numbers are NOT ACCEPTABLE case numbers.

Part C: Household Size Check the box for the total number of individuals living in your household. This should include all children and adults, related and unrelated, that live in a single dwelling and share income and expenses

Part D: Household Income Skip this part

Part E Certification Sign the form. Print your name and ate.

If your household does not receive benefits from the Food Assistance Program (FAP), Family Independence Program (FIP), or FDPIR, please follow these instructions:

Part A: Student Information For each student in the household PreK through 12th grade, list the last name, first name, grade level, school, and H if homeless, M if Migrant, R if Runaway or F if a Foster Child

Part B: Benefits Received Skip this part

Part C: Household Size Check the box for the total number of individuals living in your household. This should include all children and adults, related and unrelated, that live in a single dwelling and share income and expenses.

Part D: Household Income Check the box for that shows the range of annual income for all people in your household. Make sure to include all of the following income sources: work, welfare, child support, alimony, pensions, retirement, Social Security, SSI, VA benefits, child income and/or all other income. The amount should be before any deductions for taxes, insurance, medical expenses, child support, etc.

Part E: Certification Sign the form. Print your name and ate.

Part A. Student Information - Complete for each student Pre-K through 12th Grade

Part B. Benefits Received (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

Part D. Household Income

* Special Instructions for households with more than 8 people: DO NOT check the boxes above. Instead, fill in items below

Part E: Certification - The head of household or adult designee who completed this form must complete this certification section

I certify (promise) that all information on this form is true and that all income is reported to the best of my knowledge. I understand that this form may impact the amount of State or Federal funding allocated to my local school district. I understand that the information I have provided may be verified.