Socioeconomic Information Form
CONFIDENTIAL
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* Required
Student Last Name
*
Your answer
Student First Name
*
Your answer
Student Grade Level
*
Choose
PK
K
1
2
3
4
5
6
7
8
9
10
11
12
Campus
*
Choose
Elementary
Jr. High
High School
Do you receive Supplemental Nutrition Assistance (SNAP)?
*
Choose
Yes
No
Do you receive Temporary Assistance to Needy Families (TANF)?
*
Choose
Yes
No
How many members are in the household (include all adults & children)?
*
Choose
1
2
3
4
5
6
7
8
9
10
TOTAL YEARLY INCOME BEFORE DEDUCTIONS OF ALL HOUSEHOLD MEMBERS - includes wages, salary, welfare payments, child support, alimony, pensions, social security worker's comp (check on box below):
*
Choose
$1-$21,590
$21,591-$29,101
$29,102-$36,612
$36,613-$44,123
$44,124-$51,634
$51,635-$59,145
$59,146-$66,656
$66,657-$74,167
$74,168-$81,678
$81,679-$89,189
$89,190-$96,700
$96,701-$104,211
$104,212-$111,722
$111,723-$119,233
$119,234-$126,744
$126,745 & Above
SIGNATURE - In accordance with the provisions of the Protection of Pupil Rights Amendment (PPRA) no student shall be required, as part of any program funded in whole or in part by the U.S. Department of Education, to submit to a survey, analysis, or evaluation that reveals information concerning income (other than that required by law to determine eligibility for participation in a program or for receiving financial assistance under such program), without the prior written consent of the adult student, parent or legal guardian.
Parent Name (this will be used as your signature)
*
Your answer
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