Do NOT fill out this section. This is for school use only.
Status: F ________ R ________ N _________ Determining Official’s Signature: _____________ ________________ Date: _____________
HOUSEHOLD INFORMATION REPORT SY 2020 - 2021
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
H if Homeless
M if Migrant
R if Runaway
F if Foster
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
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 C
Part D
❑ 1
❑ At or below - $16,588
❑ Above $16,588 & at or below $23,606
❑ Above $23,606
❑ 2
❑ At or below - $22,412
❑ Above $22,412 & at or below $31,894
❑ Above $31,894
❑ 3
❑ At or below - $28,236
❑ Above $28,236 & at or below $40,182
❑ Above $40,182
❑ 4
❑ At or below - $34,060
❑ Above $34,060 & at or below $48,470
❑ Above $48,470
❑ 5
❑ At or below - $39,884
❑ Above $39,884 & at or below $56,758
❑ Above $56,758
❑ 6
❑ At or below - $45,708
❑ Above $45,708 & at or below $65,046
❑ Above $65,046
❑ 7
❑ At or below - $51,532
❑ Above $51,532 & at or below $73,334
❑ Above $73,334
❑ 8
❑ At or below - $57,356
❑ Above $57,356 & at or below $81,622
❑ Above $81,622
* 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
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.
______________________________________________________ ________________________________________________________ _____________________________
(Signature) (Printed Name) (Date)
__________________________________________________________________________________________________________
(Address) (City) (Zip)
_________________________________________________________________________________________________________
(Email Address) (Home Phone) (Work Phone)