D109 2026-2027 Fee Waiver Form

2026-2027 Fee Waiver Application
Please complete the form below, and include the information for any children who will be students attending District 109 for the 2026-2027 school year. Complete this application fully, and submit it along with your income verification documents. You can upload those documents in this form or send the documents to Rosa Castillo, District Office Receptionist via email at rcastillo@dps109.org OR via postal mail or in person at 517 Deerfield Rd, Deerfield, IL 60015. You must apply each year to receive a fee waiver.

If you are currently receiving any of the following benefits, you automatically receive a fee waiver; you do not need to apply:
- SNAP benefits
- TANF
- Foster child status
- McKinney-Vento status
There are two types of fee waivers in District 109:
1. Full Fee Waiver: All district fees are waived and the student receives free lunch every day.
2. District Fee Waiver: All district fees are waived, but the student does not receive free lunch.
You will receive notification of approval or denial via both email and postal mail.
Email Address
example@example.com
D109 Student Information
Child 1 Full Name

First NameLast Name
Child 1 School (2026-2027 School Year)
Child 1 Grade (2026-2027 School Year)
Child 2 Full Name

First NameLast Name
Child 2 School (2026-2027 School Year)
Child 2 Grade (2026-2027 School Year)
Child 3 Full Name

First NameLast Name
Child 3 School (2026-2027 School Year)
Child 3 Grade (2026-2027 School Year)
Child 4 Full Name

First NameLast Name
Child 4 School (2026-2027 School Year)
Child 4 Grade (2026-2027 School Year)

Parent/Guardian Information
Parent/Guardian Full Name(s)
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

People in Your Household
Do the students entered in section 1 live in your household?
What is the total number of people living in your household?
What is the number of adults living in your household?
What is the number of children (under age 18) living in your household?
Are you or anyone in your household experiencing any of the following situations?
Please explain any items checked above.

Income Information
Sources of Income from the United States Department of Agriculture's Food & Nutrition Service include:

Earnings from Work
- Salary or wages from a job
- Tips, commissions, and cash bonuses
- Net income from self-employment
Earnings from the U.S. Military
- Military basic pay or drill pay (portion available to the household if deployed)
- Military cash bonuses (excluding combat pay)
- Allowance for off-base housing (including BAH but excluding MHPI)
- Allowance for food or clothing (other than FSSA)
Public Assistance
- Supplemental Security Income (SSI)
- Cash assistance from State or local government
- Housing subsidies (not including those from federal housing programs)
Alimony and Child Support

Retirement Income
- Social Security retirement or survivor’s benefits
- Railroad Retirement or Black Lung benefits
- Pension income
Unemployment and Disability
- Unemployment benefits
- Worker’s compensation
- Strike benefits
- Social Security Disability Insurance (SSDI)
- Veteran’s benefits
All Other Income
- Regular cash support from outside the household (e.g., family or friends)
- Rental income
- Interest
- Investment income or annuities
- Any other source of income used to help pay for school meals
Child Income
(Money received from outside your household that is paid directly to your children)
- A full-time or part-time job
- Supplemental Security Income (SSI), if the child is disabled
- Social Security benefits for children of a disabled, retired, or deceased parent
- Money regularly received from extended family or friends outside the household
- Money from a pension, annuity, or trust
What is the total gross annual household income (before deductions) from all people living in your household?
Federal Income Eligibility Guidelines
Does your household meet the federal income guidelines for free or reduced meals?

Income Verification
Please include income verification documents with your fee waiver application. Such documents may include, but are not limited to:
- Two pay stubs for each working member of household
- Disability benefit statement
- Unemployment statement showing benefits
- Most recent tax returns
- Parent Medicaid card or letter showing case number
- Foster placement papers
- Direct Certification letter from the State of Illinois
- Food Stamp Evidence
- Temporary Assistance for Needy Families (TANF)
You may be requested to provide updated income verification at any time, but not more often than once every 60 calendar days.
Please upload your income verification documentation, or send/drop off the documentation to Rosa Castillo via email at rcastillo@dps109.org or by mail/in person at the District Office.

Cancelof
Electronic Signature

By placing your name below, you attest that the information provided and statements made herein are true and correct.
Your Name/Electronic Signature
Should be Empty:

2026-2027 Fee Waiver Application

D109 Student Information

Parent/Guardian Information

People in Your Household

Income Information

Income Verification

Electronic Signature