Part A. Student Information
Complete for each student Pre-K through 12th Grade
Part B. Benefits Received (if applicable)
If any member of your household receives Food Assistance Program (FAP), Family Independence Program (FIP), or FDPIR, provide the name and case number for the person who receives benefits. Bridge Card Numbers and Medicaid Numbers are NOT ACCEPTABLE case numbers.
Part C. Household Size
Part D. Household Income
Select the appropriate range of combined annual income for all people in the household (Include all income sources before taxes.)
Part E: Certification
The head of household or adult designee who completed this form must complete this certification section
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Certify Report(REQUIRED)