Household Income Form¶

Help us provide the best education possible for your children. Filling out this form only takes a few minutes. It will help your community, your school and your property taxes.

The information you give helps your school access federal and state education dollars. This funding supports reading, math, science, arts, PE, afterschool and other vital programming. The privacy of your household financial information is protected by law. Your information collected through this electronic form will come securely to the Agency of Education's (AOE) data team who will send it again securely back to your child's school.

Only one form needed per household.

Contact Information

Please fill out the following with information. It will only be used to contact you if if there are questions with your submission.

Your First Name Your Last Name Your Phone Town Of Residence

Student Information

Instructions: List all students in the household, Pre-Kindergarten through grade 12. Please be sure to use the student's legal name.

Student First Name

Student Middle Initial

Student Last Name

Student Date of Birth

Grade

School

Household Income Information

Instructions: Please select your household size and then select the appropriate income range for that household size.

Household size is the total number of people, including all children and adults, related and un-related, that live with you and share income and expenses.

Combined Annual income is the total amount of income of all household members, including children, from the following sources: Work, public assistance, child support, alimony, pensions, retirement, Social Security, SSI, VA benefits, and/or all other income. The amount should be before any deductions for taxes, insurance, medical expenses, child support, etc.

Household Size

Household Income Per Year

*I certify (promise) that all information on this application is true, to the best of my knowledge, and that all income is reported.