Household and Income Form

Only one form is needed PER HOUSEHOLD since all students are listed on a single form. If you have already completed a Household & Income Form for your household check the box below, then scroll to the bottom of the page and click "Submit".

I have already submitted a Household and Income Form for my household

(If you need assistance completing this form please contact the Family Resource Center at the school)

Part 1: All Household Members (a household member is any child or adult living with you): All applicants should complete this part. List the name of each household member, the name of the school each child attends, and the child’s grade. If the child is a foster child, check the box for foster child. If a household member has no income, check the box for no income. All household members, including foster children, should be included here. If you need additional space, attach a separate piece of paper.

If your child is homeless, a migrant or a runaway, follow these instructions.

Part 2: Check the appropriate category

Part 3: Skip this part.

Part 4: Sign the form

If you have foster child(ren) only, follow these instructions. You do not need to fill out a separate form for each foster child in your household. (If there are both foster children and non-foster children in your household, follow the instructions below for All Other Households

If all children in the household are marked as foster children in Part 1:

Part 2: Skip this part.

Part 3: Skip this part.

Part 4: Sign the form

ALL OTHER HOUSEHOLDS, including WIC households, households with non-foster children and households with both foster children and non-foster children, follow these instructions:

Part 2: Skip this part.
Part 3: Follow these instructions to report total household income from this month or last month .
Section 1 –Name: List all household members who have income.
Section 2 – Gross Income and How Often It Was Received: List the income for each household member. Check the box to tell us how often the person receives the income — weekly, every other week, twice a month, or monthly.

Earnings from work : List the gross income, not the take- home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. Net income should only be reported for self - owned business, farm, or rental income.

Welfare, Child Support, Alimony : List the amount each person receives, and check the box to tell us how often. o Pensions, Retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), and disability benefits . List the amount each person receives, and check the box to tell us how often they receive it.

All Other Income : List Worker’s Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income received weekly, every other week, twice a month, or monthly. Do not include income from KTAP, SNAP, WIC, federal education benefits and foster payments received by your family from the placing agency.

If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income

Part 4: An adult household member must sign the form. Please include your address and phone number in the event the FRAM Coordinator has a question about your information.

Madison County School District is participating in the Community Eligibility Provision (CEP) under the National School Lunch Program. Under CEP, all children in the school will receive a breakfast/lunch at no charge regardless of income or completion of this form. However, to determine your child(ren)’s eligibility for various additional state and federal program benefits, please complete, sign and return to school a single application per household.

PART 1. ALL HOUSEHOLD MEMBERS

	Names of all people living in your household (First, Middle Initial, Last)	School the child attends or indicate N/A if member is not in school	Grade Level	Check if a foster child (legal responsibility of the state welfare agency or court). If all children listed below are foster children, skip to Part 5 to sign this form.
1.
2.
3.
4.
5.
6.
7.

PART 2. HOMELESS, MIGRANT, RUNAWAY STATUS

If any child you are applying for is homeless, migrant, or a runaway, check the appropriate box:

HOMELESS MIGRANT RUNAWAY

PART 3. TOTAL HOUSEHOLD GROSS INCOME (before deductions). List all income on the same line as the person who receives it. Check the box for how often it is received. Record each income only once. If you provided a case number in Part 2, you do not need to provide income information. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.

DECLINE TO PROVIDE INCOME – Check this box if you don’t wish to provide your income information; your SES status will automatically be “Paid”.

Refer to example above to complete the questions below (use slide bar below table to see all colums)

	Name (List only household members w/income, including students in home who have income)	Earnings from work before deductions	Weekly	Every 2 Weeks	Twice Monthly	Monthly	Public assistance, child support, alimony	Weekly	Every 2 Weeks	Twice Monthly	Monthly	Pensions, retirement, Social Security, SSI, VA benefits, All Other Income	Weekly	Every 2 Weeks	Twice Monthly	Monthly
1.
2..
3.
4.
5.
6.

Part 4. Signature (Adult Household member must sign)

I certify (promise) that all information on this form is true and that all income is reported. I understand that the school will get state and federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my child(ren) may lose benefits. *

Clear

Type Name Below Please:

Typed name of adult signature above

Date

Street Address:

City:

State:

Zip:

Home Phone Number

Please enter a valid phone number.

Cell Phone Number

Please enter a valid phone number.

Non Discrimination Statement: In accordance with Federal Law and U.S. Department of Education policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, gender identity, age, or disability. To file a complaint of discrimination, write U.S. Department of Education, Office for Civil Rights, The Wanamaker Building, 100 Penn Square East, Suite 515, Philadelphia, PA 19107-3323 or call (215) 656-8541 (Voice Individuals who are hearing impaired or have speech disabilities may contact U.S. DOE through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish The U.S. Department of Education is an equal opportunity provider and employer.

Privacy Notice

The Kentucky Department of Education is requiring schools to collect the information on this form. You do not have to give this information, but if you do not, we cannot determine your child’s eligibility for additional benefits under state and federal programs. We will hold the information you provide us as private and confidential to the extent required by law. However, we will share your socioeconomic status with various state and federal programs to help them evaluate, fund, or determine benefits for their programs, with auditors for program reviews, and with law enforcement officials to help them look into violations of program rules. Regardless, all students enrolled in a Community Eligibility Provision school will receive meals at no charge.

HOUSEHOLD CHECKLIST

Have you included all your children as household members? For each household member receiving income, is the frequency checkbox checked? Have you signed the form?

Choose the school you wish to submit this form to. You may choose the school that any student who lives in your household attends. *

noreply@madison.kyschools.us

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Household and Income Form

HOUSEHOLD AND INCOME FORM