SOCIOECONOMIC INFORMATION FORM_2020

Complete and return one form to each school where you have a child enrolled. Print using a pen.

*CONFIDENTIAL* - For HISD purposes only

Houston ISD is required to collect the socioeconomic status of each student as a performance indicator for student achievement (TEC § 39 for Texas state requirements and ESEA §§1111 and 1116 for U.S. Department of Education requirements) and for use in disbursement of federal funds (ESEA §1113 This information is not shared with outside agencies. It is very important that families complete this socioeconomic form in order for schools to receive Title I and StateCompensatory Education funding. This funding will directly benefit your child's school. Title I and State Compensatory Education funding can be used to hire personnel, provide tutoring services, order technology, and provide professional development for teachers. We want to continue to provide these necessary learning supports, but without your assistance we may not be able to.

STEP 1 (List all Houston ISD students in the household)*

	Student ID	First Name	Last Name	MI	Date of Birth	School Name	Grade Level

Do you recieve Supplemental Nutrition Assistance (SNAP)?*

YesNo

Do you receive Temporary Assistance to Needy Families (TANF)?*

YesNo

Step 3

How many total members are in the household (include all adults and children)?*

TOTAL YEARLY INCOME BEFORE DEDUCTIONS OF ALL HOUSEHOLD MEMBERS*

Include wages, salary, welfare payments, child support, alimony, pensions, Social Security, worker’s compensation, unemployment, and all other sources of income (before any type of deductions)

STEP 4 (Check one of the following two boxes as appropriate and sign below

In accordance with the provisions of the Protection of Pupil Rights Amendment (PPRA) no student shall be required, as part of any program funded in whole or in part by the U.S. Department of Education, to submit to a survey, analysis, or evaluation that reveals information concerning income (other than that required by law to determine eligibility for participation in a program or for receiving financial assistance under such program), without the prior written consent of the adult student, parent, or legal guardian.

federal funds and will be rated for accountability based on the information I provide.*

I certify that all the information on this form is true. I understand the school will receiveI choose not to provide this information. I understand that the school’s disbursement of federal funds and accountability rating may be affected by my choice.

Parent/Guardian Name (Print)*

Signature*

Date*

Date

HISD External Funding Department | June 20

SOCIOECONOMIC INFORMATION FORM

STEP 2