Email address *
Student First Name *
Student Last Name *
Student Grade Level *
Student ID *
Student Date of Birth *
Campus *
Do you receive Supplemental Nutrition Assistance (SNAP)? *
Do you receive Temporary Assistance to Needy Families (TANF)? *
How many members are in the household (including all adults and children)? *
Total Yearly Income Before Deductions of ALL household members (check one box below): Include wages, salary, welfare payments, child support, alimony, pensions, Social Security, worker's compensation, unemployment and all other sources of income (before any type of deductions) Please Note: No part of the following information on this form will be reported to the Texas Education Agency of US Department of Education unless required in an audit. The form and its contents will be kept locally for documentation purposes only. *
I certify that the information on this form is true and that all income is reported. I understand that the school will receive federal funds and will be rated for academic accountability based on the information I provide. By typing your full name below you are acknowledging this statement and the contents of this form as accurate and true. *
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