Title 1- Income Determination Form for Private Schools 2017-2018
Please take a moment to fill out this short 3 question survey.

Your child's school is trying to qualify for extra services for their students. Please help by following the directions below to complete this form. All information is kept confidential and is only used to determine funding for the entire school, not individual students.

Please see the letter written by our Principal, Kathy Tuerk, regarding this survey:
Your family's street address: *
Your answer
Zip code: *
Your answer
Name of Private School: *
Your answer
Grade levels of all children living in your household and attending this school between Kindergarten-12th grade: *
Using the chart below, locate your family size (total number of people in your family, not just children) and the minimum income earned each month. Then answer the 3 questions below:
1. Is your monthly income equal to or less than the amount listed below in the "Income earned month" column? *
If you answered yes to #1, please select your household size below:
2. Does your family qualify for food stamps? *
3. Are you receiving Temporary Assistance to Needy Families (TANF)? (Formerly Aid to Families with Dependent Children or Public Assistance). *
Thank you, on behalf of St. Matthew's Catholic School, for taking the time to complete this survey. Have a blessed day!
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