2018/19 Household Economic Survey
Please complete the Household Economic Survey for Davenport Community Schools. This form must be filled out annually with Davenport Community Schools in order to be considered for school fee reduction or fee waiver. Only submit one form per household, not per student. Incomplete applications will NOT be processed. For questions or assistance with this form please contact EduBenefits at the Davenport Community Schools Achievement Service Center: (563) 445 - 5000 or edubenefits@davenportschools.org.
Please select one of the boxes below. *
If you have already filled out this form at another Davenport Community Schools building this year you don't need to complete a second time. You will only need to submit one form per household.
Required
Household Information
There are _____ people in the household, including children and adults.
Please enter the number of people in the household below.
Your answer
The total yearly GROSS income for ALL people in the household (income prior to tax or payroll deductions) is $___ PER YEAR. Include child support, secondary income, and any financial assistance from the state. Zero will not be accepted. Any form with zero in this field will be considered incomplete and will not be processed.
Please enter the total yearly GROSS income of ALL people in the household below. (Example: 30000 / do not enter commas to separate numbers) For assistance in determining your household income please click the following link to view and print a determination of income worksheet: https://goo.gl/oLMPqw
Your answer
Student Information
Please list your Student(s) Names, School and Grade Level for 2018/19 below. Information should be entered for all students. Example: Johnny Test, Adams Elementary, 5th Grade
Student #1
Your answer
Student #2
Your answer
Student #3
Your answer
Student #4
Your answer
Additional Students
Please list any additional students here. Example: Johnny Test, Adams Elementary, 5th Grade
Your answer
Students' Household Address
Please list your home address below
Your answer
Certification & Electronic Signature
By electronically signing below I certify that I am the parent/guardian of the student(s) listed above and that the total gross income for the household reported is accurate. I understand school officials may ask for verification of the above information. If any false information is given, I may lose benefits.
First & Last Name of Parent/Guardian *
Your answer
Phone Number of Parent/Guardian
Please enter your phone number below in the following format (xxx) xxx - xxxx
Your answer
Date of Signature *
MM
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DD
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YYYY
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