HOUSEHOLD INCOME INFORMATION
Rochester Area School District receives federal funding for student programs such as free breakfast, lunch and dinner based on household income. Please review the chart and check YES if your total household income is the same or less than the amounts indicated for your household or NO if your household income is above the amounts below.
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Household Income Chart
Please review the chart and select one of the following:
Student Name (Please list the names and grades of all of your children. For example, Jim Smith - 6, Jane Smith - 3)
Your answer
Parent/Guardian Name(s)
Your answer
Electronic signature (enter your name, please)
Your answer
Date
MM
/
DD
/
YYYY
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