Income Survey: E-rate Year 2012

Please complete the survey and sign at the bottom. All information will be kept confidential, no names will be released.

1. List all of the students in your family that attend the district (attach additional pages if necessary):

    Name
    Address
    Grade
    School
           
           
           
           
           

2. Total number of household members: __________________

3. Is your annual household income less than or equal to the amount shown below for your family size? (Check One)

YES ______ NO______

Household Size (Adults & Children)
Annual Income
 Monthly Income
1
$ 20,147
$ 1,679
2
$ 27,214
$ 2,268
3
$ 34,281
$ 2,857
4
$ 41,348
$ 3,446
5
$ 48,415
$4,035
6
$ 55,482
$ 4,624
7
$ 62,549
$ 5,213
8
$ 69,616
$ 5,802
Each Additional Family Member
Add $7,067 for each member
$589 monthly for each additional

4. Does your family participate in any of the following programs? (Check One)

YES ______ NO______

Medicaid - Food Stamps - Federal Housing or Section 8 - Supplementary Security Income - Low Income Home Energy Assistance Program

The above information is true and accurate to the best of my knowledge:

Signature: __________________________________ Date: ____________________