Household Information Report SY 2022 - 2023

Downloadable PDF Form: DEPSA | NPCP | NPGA | NPLA | UYA

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


Certify Report(REQUIRED)