ACS APPLICATION FOR CURRICULAR MATERIAL ASSISTANCE AND OTHER ASSISTANCE
Name of All Members of Household (First, Middle, and Last Name)
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In the same order you provided the names as above, Please state whether or not each person currently lives with a parent or legal guardian.
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Please state which school building along with the Students name(s)
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Please state the name and grade level of each student
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Please state the name and birthdate of each student
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For each member of your household, please state their name and whether or not they are a foster child.
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For each member of your household, please state their name and whether or not they are homeless, migrant, or a runaway.
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If any of the members of your household have no income, please state their name.
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If any member of your household (student, adult or non-student) has a valid Food Stamp (SNAP) or TANF case number, please provide the name of the person who receives benefits, check the box indicating the benefit program, and enter the case number.
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For each member of your household, please state their work earnings and what pay schedule they adhere to. (IE: Weekly, Bi-weekly, monthy, ETC)
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For each member of your household, please state their earnings from Public Assistance, Child Support, Alimony and how frequently these payments are received. (IE: Weekly, Bi-weekly, monthly, ETC)
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For each member of your household, please state their earnings from pensions or retirement and how frequently these payments are received. (IE: Weekly, Bi-weekly, monthly, ETC)
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For each member of your household, please state their earnings from any additional source that you were not asked to provide above. (IE: Weekly, Bi-weekly, monthly, ETC)
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Do you want to receive Curricular Material assistance *
Please provide the last 4 digits of your social security number.
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By typing your name in the field below, you are authorizing Anderson Community Schools to release the information on this application for curricular material assistance. I give up my right of confidentiality for this purpose only. The application may be subject to audit by the State of Indiana to determine student eligibility for curricular materials. The application information may be shared with the Indiana Family and Social Services Administration pursuant to I.C.20-33-5-2 and I.C. 12-14-28-2, solely for purposes of complying with 45 C.F.R. PARTS 260 AND 265 and for the purpose of identifying children who may qualify for free or low-cost health insurance under Medicaid or Hoosier Health wise. I certify that I am the parent/guardian of the child(ren) for whom application is being made and authorize the release of information for the purposes outlined in the application. Any false information provided is a violation of law. *
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