Federal Programs Application

STEP 1: HOUSEHOLD MEMBERS – Complete the following information for any child, newborn through 12th Grade, living in the home.

Child 1

First Last

Is this child a student?

Yes

Current Grade of Child 1

Check all that apply

Foster Child

Homeless, Migrant, Runaway

Child 2

First Last

Is this child a student?

Yes

Current Grade of Child 2

Check all that apply

Foster Child

Homeless, Migrant, Runaway

Child 3

First Last

Is this child a student?

Yes

Current Grade of Child 3

Check all that apply

Foster Child

Homeless, Migrant, Runaway

Child 4

First Last

Is this child a student?

Yes

Current Grade of Child 4

Check all that apply

Foster Child

Homeless, Migrant, Runaway

Child 5

First Last

Is this child a student?

Yes

Current Grade of Child 5

Check all that apply

Foster Child

Homeless, Migrant, Runaway

Child 6

First Last

Is this child a student?

Yes

Current Grade of Child 6

Check all that apply

Foster Child

Homeless, Migrant, Runaway

Child 7

First Last

Is this child a student?

Yes

Current Grade of Child 7

Check all that apply

Foster Child

Homeless, Migrant, Runaway

Child 8

First Last

Is this child a student?

Yes

Current Grade of Child 8

Check all that apply

Foster Child

Homeless, Migrant, Runaway

Child 9

First Last

Is this child a student?

Yes

Current Grade of Child 9

Check all that apply

Foster Child

Homeless, Migrant, Runaway

Child 10

First Last

Is this child a student?

Yes

Current Grade of Child 10

Check all that apply

Foster Child

Homeless, Migrant, Runaway

STEP 2: Do any HOUSEHOLD MEMBERS (including you) participate in one or more of the following: SNAP, TANIF, FDPIR?

SNAP*

Yes

If Yes, please write a case number here.

TANF*

Yes

If Yes, please write a case number here.

FDPIR*

Yes

If Yes, please write a case number here.

STEP 3 PART A: CHILD INCOME (SKIP THIS STEP IF YOU ANSWERED "YES" IN STEP 2)

Sometimes children in the household earn or receive income. Please include the TOTAL income received by all HOUSEHOLD MEMBERS listed in STEP 1.

A. Child Income

Please include the TOTAL income received by all HOUSEHOLD MEMBERS listed in Step 1.

How Often?

Does Not Apply To Me

Weekly

Bi-Weekly

2x Month

Monthly

STEP 3 PART B: ADULT INCOME (SKIP THIS STEP IF YOU ANSWERED "YES" TO STEP 2)

List all Household Members not listed in Step 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total gross income (before taxes) for each source in whole dollars (no cents) only. If they do not receive income from any source, type “0”. If you enter “0” or leave any field blank, you are certifying (promising) that there is no income to report.

Adult Household Member 1

First Last

Earnings From Work

How Often?

Does Not Apply To Me

Weekly

Bi-Weekly

2x Month

Monthly

Received Public Assistance/Child Support

How Often?

Does Not Apply To Me

Weekly

Bi-Weekly

2x Month

Monthly

Received Pensions/Retirement/All Other Income

How Often?

Does Not Apply To Me

Weekly

Bi-Weekly

2x Month

Monthly

Adult Household Member 2

First Last

Earnings From Work

How Often?

Does Not Apply To Me

Weekly

Bi-Weekly

2x Month

Monthly

Received Public Assistance/Child Support

How Often?

Does Not Apply To Me

Weekly

Bi-Weekly

2x Month

Monthly

Received Pensions/Retirement/All Other Income

How Often?

Does Not Apply To Me

Weekly

Bi-Weekly

2x Month

Monthly

Adult Household Member 3

First Last

Earnings From Work

How Often?

Does Not Apply To Me

Weekly

Bi-Weekly

2x Month

Monthly

Received Public Assistance/Child Support

How Often?

Does Not Apply To Me

Weekly

Bi-Weekly

2x Month

Monthly

Received Pensions/Retirement/All Other Income

How Often?

Does Not Apply To Me

Weekly

Bi-Weekly

2x Month

Monthly

Adult Household Member 4

First Last

Earnings From Work

How Often?

Does Not Apply To Me

Weekly

Bi-Weekly

2x Month

Monthly

Received Public Assistance/Child Support

How Often?

Does Not Apply To Me

Weekly

Bi-Weekly

2x Month

Monthly

Received Pensions/Retirement/All Other Income

How Often?

Does Not Apply To Me

Weekly

Bi-Weekly

2x Month

Monthly

Adult Household Member 5

First Last

Earnings From Work

How Often?

Does Not Apply To Me

Weekly

Bi-Weekly

2x Month

Monthly

Received Public Assistance/Child Support

How Often?

Does Not Apply To Me

Weekly

Bi-Weekly

2x Month

Monthly

Received Pensions/Retirement/All Other Income

How Often?

Does Not Apply To Me

Weekly

Bi-Weekly

2x Month

Monthly

STEP 3 PART C: TOTAL HOUSEHOLD MEMBERS

Total Number of Household Members (Children + Adults)*

Please enter the total number of household members entered from Step 1 and Step 3.

SSN*

Please enter the last four digits of Social Security Number (SSN) of the Primary Wage Earner or Other Adult Household Member

Check if no SSN

No SSN

Consent

Name of person completing this form*

First Last

Enter the name of the person completing this form. The name entered should be the primary contact for an Eschool student.

Date*

MM slash DD slash YYYY

Consent*

“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection the the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, I may be prosecuted under applicable State and Federal laws.”

Phone

This field is for validation purposes and should be left unchanged.

STEP 1: HOUSEHOLD MEMBERS – Complete the following information for any child, newborn through 12th Grade, living in the home.

STEP 2: Do any HOUSEHOLD MEMBERS (including you) participate in one or more of the following: SNAP, TANIF, FDPIR?

STEP 3 PART A: CHILD INCOME (SKIP THIS STEP IF YOU ANSWERED "YES" IN STEP 2)

STEP 3 PART B: ADULT INCOME (SKIP THIS STEP IF YOU ANSWERED "YES" TO STEP 2)

STEP 3 PART C: TOTAL HOUSEHOLD MEMBERS

Consent

Learn More!

Learn More!