2024-25 Household Information Survey

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The information below will be used to determine eligibility for programs that use free/reduced status for benefits such as fee waivers and utility discounts. This is not an application for free/reduced meals.

Email *

School Name *

HCVS

Parent Name *

Street Address *

City *

State *

Zip *

Student Legal Name (As on Birth Certificate)-List all students enrolled with HCVS *

Student ID-List all students enrolled with HCVS (These are the numbers in their email addresses) *

Student Date of Birth-List all students enrolled with HCVS *

Student Grade-List all students enrolled with HCVS *

Please check the box to the right of your Household Size to indicate your Annual Gross Income

Household Size is 2 check the box to the right to indicate whether your income is

Below $37,814

Above $37,814

Income

Household Size is 3 check the box to the right to indicate whether your income is

Below $47,767

Above $47,767

Income

Household Size is 4 check the box to the right to indicate whether your income is

Below $57,720

Above $57,720

Income

Household Size is 5 check the box to the right to indicate whether your income is

Below $67,673

Above $67,673

Income

Household Size is 6 check the box to the right to indicate whether your income is

Below $77,626

Above $77,626

Income

Household Size is 7 check the box to the right to indicate whether your income is

Below $87,579

Above $87,579

Income

Household Size is 8 check the box to the right to indicate whether your income is

Below $97,532

Above $97,532

Income

Household Size is 9 check the box to the right to indicate whether your income is

Below $107,485

Above $107,485

Income

Household Size is 10 check the box to the right to indicate whether your income is

Below $117,438

Above $117,438

Income

Household Size is 11 check the box to the right to indicate whether your income is

Below $127,391

Above $127,391

Income

Household Size is 12 check the box to the right to indicate whether your income is

Below $137,344

Above $137,344

Income

Signature: An adult household member must sign the application.

I certify that all information on this application is true and that all income is reported.

Please Type your full Name to serve as your signature

A copy of your responses will be emailed to the address you provided.

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