NPFE Household Information Report

Household Information Report SY 2021 - 2022

District
School

Part A. Student Information

Complete for each student Pre-K through 12th Grade

Student's Last Name
Student's First Name
Grade Level
School
Identify

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.

Name
Case Number

Part C. Household Size

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.)

Annual Household Income

*Special Instructions for households with more than 8 people: DO NOT check the boxes above. Instead, fill in items below:

Household Size (# people)
Total Annual Income

Part E: Certification

The head of household or adult designee who completed this form must complete this certification section

Print Signature
First Name
Last Name
Date

Address
City
State
Zip

Email Address
Home Phone
Work Phone

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Certify Report(REQUIRED)

I certify (promise) that all information on this form is true and that all income is reported to the best of my knowledge. I understand that this form may impact the amount of State or Federal funding allocated to my local school district. I understand that the information I have provided may be verified.