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For Office Use Only
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Please Circle One
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Income Eligible: Yes / No
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If yes, and enrolled, student should be classified as (L) in student information system
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2025-2026
Application to Determine Income Eligibility for the Voluntary Pre-K Program
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Completion of this form DOES NOT qualify your child for the Free or Reduced Meal Program. Submission of this application is not a guarantee of acceptance into the VPK program.
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Name of Student:Date of Application:
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SSN of Student (optional):Date of Birth of Student:
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Name of Applicant:Relationship to Student:
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Mailing Address:
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City:State:Zip Code:
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Home
Phone #:		( )Work
Phone #:		( )Cell Phone #:( )
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Part A - Family Information
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Please list information for all other household members
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Section 1
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Name(s) of ALL OTHER CHILDREN in the HouseholdDate of BirthSchoolGrade
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1.
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2.
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3.
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4.
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Section 2
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Name(s) of ALL OTHER ADULTS in the HouseholdRelationship to Student
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1.
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2.
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3.
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4.
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5.
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Total # of household members:
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Part B - Program Participation
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Please check (√) if Child /Family /Household member provides documentation of participation, in one or more of the following programs, currently or during past school year (*Documentation required-See Part D).
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(√)(√)(√)(√)Case #
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Early Head StartFoster CareMigrantFamilies First (TANF)
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Head StartHomelessFood Stamps / EBT
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Part C - Total Household Income
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Please list ALL INCOME of all household family members and how often income is received.
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Any falsification of information concerning income, residence, birth certificate and/or completion of this application and other forms may be reason for dismissal.
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Income Instructions
From the list below, please write the Source of Income Code in the space provided to indicate the source(s) of income for each earning individual in the household. Also, please write the Monthly Payment or Wage Amount. Multiply the Payment or Wage amount by the number months you received the income and then calculate the Amount and the Total Annual Income.
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Source of Income Codes
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A.GROSS work incomeD.Pension(s)G.Veteran's BenefitsJ.SSI Disability
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B.UnemploymentE.RetirementH.Child SupportK.Other - please list ↓
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C.Workman's CompF.Social SecurityI.Alimony
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Name of AdultEmployer (if applicable)Source of Income Code (See list above)Monthly Payment or Wage AmountMultiplied by
(X)		How many months did you receive this income in the last year?Total Amount
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 $ - X $ -
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 $ - X $ -
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 $ - X $ -
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 $ - X $ -
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 $ - X $ -
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Total Annual (Yearly) Income $ -
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Part D - INCOME VERIFICATION
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Please check (√) all documents submitted as Proof of Income or Program Participation.
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Pay Stub / Verification of pay by employerRetirement DocumentationFoster Care Reimbursement
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W-2 FormSocial SecuritySSI Documentation
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Income Tax Form 1040A or 1040Veteran's Benefit LetterTANF Documentation
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Unemployment CompensationChild SupportAFDC / Public Assistance Payment
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Workman's Compensation DocumentationAlimony DocumentationTennCare Verification
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Pension StubsOther (Specify): →
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I certify that the above information in this application is correct. I further understand that any falsification of information concerning income, residence, birth certificate and/or completion of this application and other forms may be reason for dismissal from Tennessee's Voluntary Pre-K Program.
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Printed Name of Applicant:SSN #:
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Signature of Applicant:Date:
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Name and Signature of LEA employee reviewing this application
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I certify that I have examined the above income documentation and verification information. Completed forms must be maintained in accordance with FERPA.
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Printed Name / Title of LEA employee:
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Signature of LEA employee:
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Date Reviewed by LEA employee:
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