Household Income Survey - Oregon



Survey Number: ____________(For School Use Only)Household Income Survey 2019-2020Even if your income does not meet these Income Eligibility Guidelines, you must return the survey in order for the school’s survey to be valid.Your Address: ________________________ City ______________ ST ___________ Zip _____________1. Circle your household size below, and then answer the following questions:Household Size (Circle One)Est. Annual Income (As Reported to IRS)Monthly IncomeIf Paid Two times per mo.If Paid Every Two WeeksWeekly Income-1-23,1071,926963889445-2-31,2842,6071,3041,204602-3-39,4613,2891,6451,518759-4-47,6383,9701,9851,833917-5-55,8154,6522,3262,1471,074-6-63,9925,3332,6672,4621,231-7-72,1696,0153,0082,7761,388-8-80,3466,6963,3483,0911,546For each additional family member add8,177682341315158Is your income equal to or less than any of the amounts listed next to the number you circled? FORMCHECKBOX Yes FORMCHECKBOX NoIs your family participating in the Supplemental Nutrition Assistance Program (SNAP) - Oregon Trail Card? FORMCHECKBOX Yes FORMCHECKBOX NoIs your family participating in Temporary Aid to Needy Families (TANF)? FORMCHECKBOX Yes FORMCHECKBOX NoIs your family receiving Food Distribution Program on Indian Reservations ( FDPIR)? FORMCHECKBOX Yes FORMCHECKBOX NoDo your students receive foster, migrant, homeless or runaway education services? FORMCHECKBOX Yes FORMCHECKBOX No2. Please list all students in your household that attend school. (Enter the grade they will be entering in Fall, 2019. Write on back to list more than 5 students)NameGradeSchool3. Certification: I certify that the above information is, to the best of my knowledge, true and complete.Signed: _________________________________Date: _______________Household Income Survey 2019-2020 ................
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