Parenting Class Income Questionnaire

In order to provide these services to you free of cost, we collect some information about you for our funders. We NEVER share your name or other personally identifying information with anyone outside our program without your permission unless required by law.

program

Name *

First Name Last Name

You do not need to meet the income guidelines in order to receive services. We collect this information to determine which funding source(s) can pay for your services.

2022 CSBG Income Guidelines

Household Size	1	2	3	4	5	6	7	8
Yearly	27,180	36,620	46,060	55,500	64,940	74,380	83,820	93,260
Monthly	2,265	3,052	3,828	4,625	5,412	6,199	6,985	7,772

For families with more than 8 persons, add $4,720 yearly for each additional person.

Is your household income at or below the guidelines shown? *

Yes No

Gender

Male Female Other

Age

18-24 25-44 45-54 55-59 60-64 65-74 75+

Ethnicity

Hispanic/Latino Not Hispanic/Latino

Race

American Indian or Alaska Native Asian Black or African American Native Hawaiian and Other Pacific Islander White Other Multi-race

HouseholdType

Single Person Two Adults, NO Children Single Parent Female Single Parent Male Two Parent Household Multigenerational Non-related Adults with Children Other

Number of people in household:

I verify that the above information is accurate. (Please initial) *

Clear

incomequal