P.A.C.E. Academy Household Information Report School Year 2020 - 2021
This survey is used to determine eligibility for State benefits for which your child(ren)'s school may qualify.
Email address *
Part A. Student Information - Complete for each student Pre-K through 12th Grade
Student Information – For each student in the household Pre-K through 12th grade, list
the last name, first name, grade level, and list if Homeless, Migrant, Runaway or a Foster Child.
Student #1 Last, First Name *
Student #1 Grade Level *
Student #1 is *
Student #2 Last, First Name
Student #2 Grade Level
Student #2 is
Clear selection
Student #3 Last, First Name
Student #3 Grade Level
Student #3 is
Clear selection
Student #4 Last, First Name
Student #4 Grade Level
Student #4 is
Clear selection
Student #5 Last, First Name
Student #5 Grade Level
Student #5 is
Clear selection
Student #6 Last, First Name
Student #6 Grade Level
Student #6 is
Clear selection
Part B. Benefits Received (if applicable)
If any member of your household receives Food Assistance Program (FAP), Family Independence Program (FIP), or FDPIR, provide the name and case number for the person who receives benefits. Bridge Card Numbers and Medicaid Numbers are NOT ACCEPTABLE case numbers.
Name
Case Number
Part C. Household Size - Total number of members in your household. Part D: Household Income - Total income for your household.
Part C & D Instructions:
Part C: Household Size - Complete ONLY the section below that coincides with the total number of individuals living in your
household. This total includes ALL children and adults, related and unrelated, that live in a single dwelling and share income and expenses.

Part D: Per your household size, please check the box that shows the range of annual income for all people
in your household. Make sure to include all of the following income sources: work, welfare, child support, alimony, pensions, retirement, Social Security, SSI, VA benefits, child income and/or all other income. The amount should be before any deductions for taxes, insurance, medical expenses, child support, etc.
Complete this section ONLY if you are the only member in your household.
At or below - $16,588
Above $16,588 & at or below $23,606
Above $23,606
1 member
Complete this section for a TWO member household
At or below - $22,412
Above $22,412 & at or below $31,894
Above $31,894
2 members
Complete this section for a THREE member household
At or below - $28,236
Above $28,236 & at or below $40,182
Above $40,182
3 members
Complete this section for a FOUR member household.
At or below - $34,060
Above $34,060 & at or below $48,470
Above $48,470
4 members
Complete this section for a FIVE member household.
At or below - $39,884
Above $39,884 & at or below $56,758
Above $56,758
5 members
Complete this section for a SIX member household.
At or below - $45,708
Above $45,708 & at or below $65,046
Above $65,046
6 members
Complete this section for a SEVEN member household.
At or below - $51,532
Above $51,532 & at or below $73,334
Above $73,334
7 members
Complete this section for an EIGHT member household.
At or below - $57,356
Above $57,356 & at or below $81,622
Above $81,622
8 members
*Special Instructions for households with more than 8 people: DO NOT check the boxes above. Instead, fill in Household size (# people) & Total annual income
TECH CONNECTION QUESTIONS
Does your household have Wi-Fi connection? *
What is the total number of children in your home who are attending PACE Academy's Virtual Learning Academy? *
Would your kid(s) benefit from an external mouse for their Chromebook? *
Would your Kid(s) benefit from headphones for their Chromebook? *
Part E: Certification - The head of household or adult designee who completed this form must complete this certification section
I certify (promise) that all information on this form is true and that all income is reported to the best of my knowledge. I understand that this form may impact the amount of State or Federal funding allocated to my local school district. I understand that the information I have provided may be verified.
Printed Name to be used as official Signature *
Street *
City, State, Zip *
Phone Number *
A copy of your responses will be emailed to the address you provided.
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