SmartForm Submission of Additional Income Info Form

Families First of Minnesota Head Start & Early Head Start
126 Woodlake Drive SE Rochester MN 55904
(507) 287-2009

Submission of Additional Income Info Form

Please use this form to submit additional income related documents to go along with your original application. These documents or statements have been deemed necessary to verify eligibility.

Acceptable document formats for uploading/submitting here are: pdf, doc, docx, xls, xlsx, csv, jpg, jpeg, png, gif

Please note, income eligibility guidelines are established for participation Head Start programs based on the poverty guidelines updated annually by the US Department of Health and Human Services Grantees are required to verify family income documents such as pay stubs, or W-2s to determine if the child/woman is income eligible. As is the case with those categorically eligible, we are required to retain a record of the documents reviewed and relied upon to determine that a child is income eligible accompanied by a statement signed by an employee of the Head Start grantee that the child was found to be eligible.

Please fill in as much as you can - this will help us match everything up!

Select your County of application: *

Olmsted Freeborn Winona

Enter the name of the parent/guardian who originally completed and signed your Head Start application: *

Parent First Name Parent Last Name

Enter the name of the child you are applying for: *

Child's First Name Child's Last Name

Enter the date of birth of the child you are applying for: *

Child's Birth Date

What telephone number is best to contact you at if we have questions: *

Your Contact Phone Number

What email address did you use on your application, which we can reach you at:

example@example.com

Browse and Upload your Income Related Documents here - Total combined maximum file size 5MB please. File types for upload include PDF, DOC/DOCX, JPG/JPEG or PNG only: *

Enter your Signature here: *

Clear

Today's date: *

Date