This form is used to determine eligibility for state benefits for which your child(ren)'s school may qualify. Please complete, sign, and return this form to your child's school.

If any member of your household receives benefits from the Food Assistance Program (FAP), Family Independence Program (FIP), or FDPIR, please follow these instructions:

Part A: Student Information For each student in the household Pre-K through 12th grade, list the last name, first name, grade level, school, and H if homeless, M if Migrant, R if Runaway or F if a Foster Child.

Part B: Benefits Received If any household member, including adults, receives Food Assistance Program (FAP), Family Independence Program (FIP), or Food Distribution Program on Indian Reservations (FDPIR), provide the name and case number. Bridge Card Numbers and Medicaid Numbers are NOT ACCEPTABLE case numbers.

Part C: Household Size Check the box for the total number of individuals living in your household. This should include all children and adults, related and un-related, that live in a single dwelling and share income and expenses.

Part D: Annual Household Income Skip this part

Part E: Certification Sign the form. Print your name and date.

If your household does not receive benefits from the Food Assistance Program (FAP), Family Independence Program (FIP), or FDPIR, please follow these instructions:

Part A: Student Information For each student in the household Pre-K through 12th grade, list the last name, first name, grade level, school, and H if homeless, M if Migrant, R if Runaway or F if a Foster Child.

Part B: Benefits Received - Skip this part

Part C: Household Size Check the box for the total number of individuals living in your household. This should include all children and adults, related and un-related, that live in a single dwelling and share income and expenses.

Part D: Annual Household Income Moving across the same row as the household size check box, check the box that shows the range of annual income for all people in your household. Make sure to include all of the following income sources: work, welfare, child support, alimony, pensions, retirement, Social Security, SSI, VA benefits, child income and/or all other income. The amount should be before any deductions for taxes, insurance, medical expenses, child support, etc.

Part E: Certification - Sign the form. Print your name, date, and contact information.

District: Big Rapids Public Schools, Big Jackson Public Schools & Mecosta-Osceola Intermediate Schools: Brookside, Eastwood, Riverview, Middle School, High School, Virtual School, Big Jackson, MOEC, GSRP

If any member of your household receives Food Assistance Program (FAP), Family Independence Program (FIP), or FDPIP, provide the name and case number for the person who receives benefits. Bridge Card Numbers and Medicaid Numbers are NOT ACCEPTABLE case numbers.

I certify (promise) that all information on this form is true and that all income is reported to the best of my knowledge. I understand that this form may impact the amount of State or Federal funding allocated to my local school district. I understand that the information I have provided may be verified.