CCISD Income Verification Form

Part I:  Children in School

Names of All Children in School (Last, First, Middle Initial

Campus Name

Student ID Number or Social Security Number

Grade

Eligibility Group # for Food Stamps or TANF (if any)

1.

2.

3.

4.

5.

6.

7.

8.

Part 2:  Household Members and Gross Income from Last Month (list each person in household. 

1.  Name (list everyone in household)

2.  Income and Frequency. 

·         Weekly (W)

·         Every Two Weeks (E)

·         Twice a Month (T)

·         Monthly (M)

3.  Check (√) if NO Income

Earning from Work Before Deductions

Welfare, Child Support, Alimony

Pension, SS, Retirement

Other

1.

2.

3.

4.

5.

6.

Part 3:  Signature and Social Security Number (Adult Must Sign)

Names of All Children in School (Last, First, Middle Initial

Campus Name

Student ID Number or Social Security Number

Grade

Eligibility Group # for Food Stamps or TANF (if any)

An adult household member must sign the form.  If Part 2 is complete, the adult signing the form must also list his or her Social Security number or mark the “I do not have a Social Security Number” box.  (See Privacy Act statement on the instructions for Applying page).

I certify (promise) that all information on this form is true and that all income is reported.  I understand that the school will get federal funds based on the information I give.  I understand that school officials may verify (check) the information.

Sign here:  ______________________________________________________                       Date:  _____________________

Social Security Number:  __________  _____   __________                                               I do not have a SSN.

Printed Name:  ________________________________     Home Phone:   _____________   Work Phone:  ______________

Mailing Address:  _____________________________      City:  _________________  State:  _____     Zip:  _____________

For School Use Only

Multiple income frequencies must be converted to annual amounts and combined to determine household income.  If converting household income to annual amounts, round to the nearest tenth.  Do not convert of the household provides only one income frequency.

Household income:  __________     Household Size:  __________     FS/TANF:  __________    

Date Withdrawn:   __________

Eligibility:     Free:  _________     Reduced:  _________    Denied:  __________   

Reason:  _____________________________________________________________________________________

Reviewing Official Signature:  ____________________________________     Date:  _______________

Central Office PEIMS Clerk:  _____________________________________      Date:  _______________