2021-2022 Household Economic Survey

Do not complete this form if you are Directly Certified to receive free meals or if you have filled out a Child Nutrition Program Meal Benefits Application

For your school to receive specific state and federal benefits and funding, you must fill out this form.

There are _____ people in my household, including all children and adults.

The total annual income for all people in the household before any deductions for taxes, insurance, medical expenses, child support, etc. is _____ per year.

Student Information - Please add additional students as needed

First Name

Last Name

School School

Grade

Date of birth

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I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will receive federal and state funding based on the information provided. I understand that school officials may verify (check) the information.

Parent/Guardian - Please enter your first and last name as your electronic signature.

Today's Date

Phone