Household Economic Survey
For our district to receive specific state and federal benefits and funding, you must fill out this form. Do NOT complete this form if you are Directly Certified to receive free meals.
There are ____ people in my household, including all children and adults.
*
Please Select
1
2
3
4
5
6
7
8
9
10
10+
The total annual income for all people in the household before any deductions for taxes, insurance, medical expenses, child support, etc is *$_____* per year.
*
Please list the name, school, grade and date of birth of ALL children living in your household.
*
I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will receive federal and state funding based on the information provided. I understand that school officials may verify (check) the information.
*
Please Select
Yes
No
I understand that the submission of this form serves as my “electronic” signature and replaces a hand written signature in all questions answered above.
*
Please Select
Yes
No
Please list your first & last name and phone number below.
*
Submit
Should be Empty: