Title I Household Data Collection Form 2020-2021
Dear Parent/Guardian:

Your school participates in a program that provides school meals at no cost to all students in the school regardless of their meal status. This program is called Community Eligibility Provision (CEP) and is provided through the United States Department of Agriculture (USDA).

Households with children in a CEP school do not fill out the Free and Reduced-Priced Meals Benefit application. However, our school system benefits from many grants and funding opportunities based on the schools Free and Reduced Meals percentage (FARMs). Therefore, we hope you will complete the attached form to help your school receive additional funding.

Should you have any questions regarding this form, please feel free to contact your school’s principal or the Title I Office at 410-677-4563.

Thank you.
Email address *
List all children in the household. Please type Last Name, Middle Name, First Name. (Example: Jones, Lake, Robert) Click enter for a new line. One child per line. *
Give the birth dates in the order of the children listed above. (Example: November 8, 2008) Click enter for a new line. One date per line. *
School attending and grade level. (Mark one box for each child.)
PreK 3
PreK 4
K
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Beaver Run
Chipman
East Salisbury
Glen Avenue
Pemberton
Pinehurst
Prince Street
West Salisbury
Directions to determine "Household Size" and "Annual Household Income"
Household Size and Annual Income
Household Size: Type below the number (1 -8) to show your household size. For households greater than 8, skip to the section below. *
Household Size Greater than 8: Type below the household size (9 or more) and total annual income. (Example: Household Size: 9 Total Annual Income: $62,500)
Household Annual Income: Choose the letter, next to your household size that shows your family's income level. (Example: If your household size is 4, choose only D or L ) Type the letter below. *
I certify that the information provided on this form is true and that I included all income. I understand that the school may receive state and federal funds based on the information I provided and that the information could be subject to review.
By typing my name below, I am electronically signing this form. *
Wicomico County Public Schools (WCPS) prohibits illegal discrimination based on race, ethnicity, color, ancestry, national origin, religion, immigration status, sex, gender, gender identity, gender expression, sexual orientation, family/parental status, marital status, age, physical or mental disability, poverty and socioeconomic status, language, or other legally or constitutionally protected attributes or affiliations and provides equal access to the Boy Scouts and other designated youth groups. Discrimination undermines our community’s long-standing efforts to create, foster, and promote equity, inclusion, and acceptance for all.
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