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2026-27 Alternate Household Income Form
Complete one form per household. Your school participates in the Community Eligibility Provision, which means all students qualify for free meals. However, to determine eligibility to receive additional benefits beyond free meals for your child(ren) and school, please complete this alternate household income form. Return this form to:
Section 1: Student Information
Instructions: List all students in the household, through grade 12. If any child you are listing is a foster child; homeless, migrant, or runaway; or attends Head Start, please check the appropriate box.
Section 1: Student Information
Rows
Student's First Name
Student's Last Name
Grade
School Child Attends
Foster
Homeless, Migrant, or Runaway
Head Start
1
2
3
4
"If more spaces are required for additional names, please attach on another sheet of paper.
Section 2: Household Income
Instructions: Your household size is the total number of people, including all children and adults, related and un-related, that live in a single dwelling and share income and expenses. Please mark your household size and then select the applicable yearly total household income range under the number of people in the 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.
Household Size
*
1
2
3
4
5
6
7
8
Income Range
$0 up to $29,526.00
$29,526.01 or more
$0 up to $40,034.00
$0 up to $50,542.00
$0 up to $61,050.00
$0 up to $71,558.00
$0 up to $82,066.00
$0 up to $92,574.00
$0 up to $103,082.00
Income Range (or more)
$29,526.01 or more
$40,034.01 or more
$50,542.01 or more
$61,050.01 or more
$71,558.01 or more
$82,066.01 or more
$92,574.01 or more
$103,082.01 or more
If your household has 9 or more people, please enter your information here:
Yearly Household Income: $
Section 3: Sharing of Information for Local Programs
The information on this form may be shared with other programs that your child(ren) may qualify for only with your permission. Information will only be shared with the program if you check the box.
Yes! I DO want school officials to share information from this form with
Yes! I DO want school officials to share information from this form with
Yes! I DO want school officials to share information from this form with
Yes! I DO want school officials to share information from this form with
No! I DO NOT want school officials to share information from this form.
Section 4: Contact Information and Adult Signature
"I certify (promise) that all information on this form is true, and that all income is reported."
Signature
*
Print Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
*Completion of this form does not qualify your child/children for Summer EBT. To apply, visit dpi.wi.gov/school-nutrition/summerebt or scan the QR code.
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