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	Monthly	Weekly
1 *	23606	1968	454
2	31894	2658	614
3	40182	3349	773
4	48470	4040	933
5	56758	4730	1092
6	65046	5421	1251
7	73334	6112	1411
8	81622	6802	1570
For each additional family member add	8288	691	160

*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*
Public school district in which you reside*
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 Grade Level
Is your annual income less than the amount identified in the table?*
- Yes
- No
Is your family eligible for food stamps?*
- Yes
- No
Are you receiving TANF Cash Assistance?*
(Temporary Assistance for Needy Families, formerly AFDC or Public Assistance)
- Yes
- No
Are any of your children eligible to receive medical assistance under the Medicaid program?*
- Yes
- No
Do you wish to share this information in writing.*
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code

Child Name	Grade Level

Family Survey

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