Income Eligibility Survey 2019-20
To comply with Dept. of Education guidelines this form must be completed annually. Schools receive additional funding for students that are either foster youth, English language learners, or whose parents are active military, receive certain types of state and/or federal assistance, or receive income below a certain amount. Completing this survey will ensure your student’s school receives the appropriate level of funding.
Email address *
1. Do you receive any of the following for your student? (Food Stamps,CalWORKs,FDPIR):
Yes
Food Stamps
CalWORKs (California Work Opportunity and Responsibility to Kids)
FDPIR (Food Distribution Program on Indian Reservation)
2. Is your student a Foster Youth, or a child who is the legal responsibility of a welfare agency, or the court?
3. Is there a parent/guardian in this household on Active Duty in the Military or Full Time National Guard?
4. Based on the size of your household, Is your income less than or equal to the amount shown on the chart below?
Captionless Image
Student's School
Student ID
Your answer
Student Grade Level
Student's First Name
Your answer
Student's Last Name
Your answer
Student's Date of Birth
MM
/
DD
/
YYYY
Parent/Guardian First & Last Name
Your answer
Parent/Guardian email address
Your answer
e-Signature: Please type name below *
Your answer
Today's Date *
MM
/
DD
/
YYYY
Submit
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