2015-2016 Alternate Household Income Form Your school is a Community Eligible school, which means all students qualify for free meals. However, to determine eligibility to receive additional benefits beyond free meals for your child(ren) and school, please complete a household income form. Return form to: Milwaukee College Prep. 1. 2. Select the total number of people in your household. Be sure to include all children and adults, related and unrelated, that live in a single dwelling and share income and expenses. Select the box that represents the range of annual household income. Make sure to include all of the following income sources: work, welfare, child support, alimony, pensions, retirement, Social Security, SSI, VA benefits, child income and/or all other income. The amount should be before any deductions for taxes, insurance, medical expenses, child support, etc. 1. Total No. of people 2. Select the appropriate range of combined annual income for all people in the in household household (Include all income sources listed above, before taxes.) 1 $0 - $21,775 At or Above $21,776 2 $0 - $29,471 At or Above $29,472 3 $0 - $37,167 At or Above $37,168 4 $0 - $44,863 At or Above $44,864 5 $0 - $52,559 At or Above $52,560 6 $0 - $60,255 At or Above $60,256 7 $0 - $67,951 At or Above $67,952 8 $0 - $75,647 At or Above $75,648 9 $0 - $83,343 At or Above $83,344 10 $0 - $91,039 At or Above $91,040 11 $0 - $98,735 At or Above $98,736 12 $0 - $106,431 At or Above $106,432 If household size is more than 12, list the household size and total annual income below. Size: _____ Income: Grade Level School Child Attends Head Start Student’s Last Name Homeless, Migrant, Runaway Student’s First Name Foster List all students in the household. If any child you are applying for is a foster child; homeless, migrant, runaway; or attends Head Start, please check the appropriate box. 2015-2016 Alternate Household Income Form, page 2 Contact information and adult signature “I certify (promise) that all information on this application is true and that all income is reported.” Name of Adult Completing the Form (printed) Signature Today’s Date Street Address (if available), Apt # ( ) Daytime Phone (optional) City State Zip Code Email CHECKLIST Have you included all your children as household members? Are both the household size and total household income range boxes checked? Have you signed the form? DO NOT FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY. Economic Status: Economically Disadvantaged (free/reduced) ______ Non-Economically Disadvantaged (paid) ______ I have reviewed the above and have concluded that it is properly and completely filled out to the best of my knowledge. Signature (of school or district staff):________________________________________________________ Print Name: ___________________________________________________________________________ Date: _____________________ Reminder: All costs associated with distributing, collecting, and reviewing these household income forms must be paid for with funds outside of the nonprofit school food service account.
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