Income Verification Form

The purpose of this form is to collect family income data in order to qualify your school for federal Title I funds and services for the 2021-2022 school year. Determining the number of students who qualify for free and reduced lunches and who also resides in Title I school attendance zones, accomplishes this goal.

To determine your Annual Gross income, multiply your weekly salary by the number of weeks or months you actually worked. Add to that number all other sources of income, including child support, alimony, retirement, SSI benefits, etc. Note that for each additional family member over eight, add $8,288.00 to Annual Gross Income. Then locate your family size and look at the qualifying annual gross income level listed beside it.

Family Size Annual Gross Income Monthly Gross Income Weekly
1 $23,606 $1,968 $454
2 $31,894 $2,658 $614
3 $40,182 $3,349 $773
4 $48,470 $4,040 $933
5 $56,758 $4,730 $1,092
6 $65,046 $5,421 $1,251
7 $73,334 $6,112 $1,411
8 $81,622 $6,802 $1,570
Each additional family member add: $8,288 $691 $160
Is your family income less than the amount (Annual, Monthly, or Weekly Gross) listed beside the number in your family size?(Required)
Is your family eligible for food stamps?(Required)
Are you receiving Temporary Cash Assistance (TCA) or Temporary Assistance to Needy Families (TANF)?(Required)
Complete Home Address(Required)
Please do not use a P.O. Box – must be a physical address including house number, street, and city.
Please list the initials, grade level, and birthdates of all children in your family who only attend this private school.(Required)
Child's Initials
Current Grade Level (22-23)
Birth Date

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