Depew UFSD 2026-2027 Alternative Household Income 
This form is utilized as an alternative means to collect income eligibility information from the student’s household and organizations should retain completed forms for a period of five years.
Definition of Income: all items such as wages and salaries before any deductions, and other income, such as self-employment, welfare, social security, retirement benefits unemployment compensation, worker’s compensation, aid for dependent children, alimony, child support,  pensions, insurance,
or annuity payments, etc.

Exclusion: the value of meals, milk, or EBT benefits to children shall NOT be considered income.
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Total number of people in the Household *
Please list household members in the above count *
Total Annual Income    Numbers only- no dollar sign *
Does your family participate in any of these programs-
-Social Security Insurance (SSI)
-Supplemental Nutritional Assistance Program (SNAP) 
-Foster Care
-Refugee Assistance ( Cash or medical assistance)
-Earned income Tax Credit
-Home Energy Assistance Program (HEAP)
-Safety Net Assistance (SNA)
-Bureau of Indian Affairs (BIA)
-Family Assistance: Temporary Assistance for Needy Families (TANF)
 *
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