□

1.

2.

3.

4.

5.

6.

7.

8.

Total #of Household Members: Total Annual Household Income

FrequencyWeekly (W) Bi-Weekly (B) Twice/Month (T)

Monthly (M)

Annually (A)

# Pays/Year(W) = 52(B) = 26

(T) = 24

(M) = 12

(A) =

1

Check here if there are more than eighthousehold members; continue on second form.

example 1. Household Member

ABC Company (Name of employer)

Bi-weekly

$

1,200

26

$

31,200

$

Gross Income

Earnings

Before

Deductions

Annual Income

Gross Income

x

#Pays/Year

Enter additional income not recorded above here:

Sources of IncomeList the source of all income for each family member. Examples: Name of employer, unemployment, child support, alimony, social security, disability, etc.

Household MembersList ALL household members including the child applying as well as any other adults and children living in the household.

Date

For income verification, please provide current tax return, two months of bank statements, or two recent pay stubs for each income listed. Documentation MUST be provided in order for a family to be considered based upon income eligibility. In the event that this information is found to be inaccurate, the child’s placement in the program may be jeopardized. No spots are held in a program if paperwork is incomplete.

Registration is not guaranteed until VERIFIED by the school.

Check the automatic qualifier box if any of these apply: 1 - The student is homeless. You MUST work with the school's Pupil Personnel Worker (PPW) for verification.2 - The student has an Individual Educational Program (IEP) for special education classroom instruction. (Does not include Related Services Only IEP (OT, PT, Speech, DHH). You MUST provide a copy of the child's IEP. 3 - Someone in the household receives Food Supplement Program (FSP), Temporary Cash Assistance (TCA) or has an Independence Card. You MUST provide a copy of your benefits card as well as a copy of the benefits letter you received indicating benefits are active.

If any of the above apply, check the Automatic Qualifier box, sign below and return to your home school.

If using an official Annual Tax Return form 1040 for income verification, enter Gross earnings here. Make sure to list all household members names below even if entering total income on the tax line.If not using a tax return to report income, or if you have additional income to report, use the chart below.

Student LAST Name Student FIRST Name

Prekindergarten(3 years old

on or before Sept. 1)(4 years old

on or before Sept. 1)

Preschool

Date of Birth (mm/dd/yyyy)

Zoned Home School

Preferred Session: AM PM None or N/A Preference does not guarantee placement in preferred session.

Income Verification and Automatic Criteria Form (Prekindergarten/Preschool) updated January 2021

Complete this form if you would like to be considered for placement in a Prekindergarten or Preschool program. Record gross income (earnings before deductions) for ALL sources of income for ALL HOUSEHOLD MEMBERS (including children and all members of a shared domicile). Sources of income may include earnings from work, unemployment, public assistance, child support, alimony, pensions, retirement, and all other income. If income from a source fluctuates, calculate the average received. If you enter a '0' or leave any fields blank, you are certifying that there is no income to report. Those who automatically qualify due to certain Benefits Programs, Educational IEPs or Homelessness do not need to report income (some exceptions may apply).

I certify that the information provided is correct. Parent/Guardian Signature

Parent/Guardian Printed Name