Family Survey

Find and your family size and the annual gross income level listed beside it on the chart printed below. The amounts are the gross income levels.

**INCOME CHART**
Family Size	Annual Income	Monthly Income	Weekly Income
1 *	$25,142	$2,096	$484
2	$33,874	$2,823	$652
3	$42,606	$3,551	$820
4	$51,338	$4,279	$988
5	$60,070	$5,006	$1,156
6	$68,802	$5,734	$1,324
7	$77,534	$6,462	$1,492
8	$86,266	$7,189	$1,659
For each additional family member add	+ $8,732	+ $728	+ $168

*This may be a foster child, an emancipated youth, or a special education child over age 18.

Please Note: If you are paid on a weekly or monthly basis, please multiply this amount into an annual figure for comparison based on the weeks or months you actually work each year.

Family Name*

Answer required for "Family Name"

Public school district in which you reside*

Answer required for "Public school district in which you reside"

Name of School Building(s) your children would attend in public school*

Answer required for "Name of School Building(s) your children would attend in public school"

List name(s) and grade level(s) of your child/children attending our school

Child Name*

Answer required for "Child Name"

Grade Level*

Answer required for "Grade Level"

Is your annual income less than the amount identified in the table?

Answer required for "Is your annual income less than the amount identified in the table?"

Yes

Is your family eligible for food stamps?

Answer required for "Is your family eligible for food stamps?"

Yes

Are you receiving TANF Cash Assistance?

(Temporary Assistance for Needy Families, formerly AFDC or Public Assistance)

Answer required for "Are you receiving TANF Cash Assistance?"

Yes

Are any of your children eligible to receive medical assistance under the Medicaid program?

Answer required for "Are any of your children eligible to receive medical assistance under the Medicaid program?"

Yes

Do you wish to share this information in writing

Answer required for "Do you wish to share this information in writing"

Yes

Address

Street Address*

Answer required for "Street Address"

Address Line 2

Answer required for "Address Line 2"

City

Answer required for "City"

Zip/Postal

Answer required for "Zip/Postal"

Please fix the highlighted areas below before submitting.

Family Survey