PDF Nonprofit Private School Eligibility Application Federal List ...

Nonprofit Private School Eligibility Application Federal List of Low Income Schools for Purposes of

Federal Teacher Loan Forgiveness

School Year: ________________________ (Example: 2011-12) Grade Range: _______________________ School Name: ______________________________________________________________ Address: __________________________________________________________________ City _____________________________________State_________ ZIP________________ County: __________________________ Phone: __________________________________ Contact Person: ____________________________________________________________ Florida Department of Education School ID Number: _______________________________ Public School District Name Where School is Located: ____________________________________________________

Does the school participate in the National School Lunch Program (NSLP) administered by the Florida Department of Agriculture, Office of Food and Nutrition? Yes ____ No____

NSLP sponsor agreement number: ___________________________________

DO NOT INCLUDE PREKINDERGARTEN STUDENTS IN EITHER COUNT BELOW.

Number of Low-Income

Students as of October 1st of the school year *

(divided by)

Total K-12 students in the school

(equals)

Percent of Low Income Students (more than 35% needed to qualify)

________________

?

________________

=

________________

* Low income determination can be verified through a current NSLP Claim Summary, Florida Tax Credit (FTC) verification of scholarship student membership, Confidential Family Income Surveys or a combination of two or more methods.

I certify that both the school and student eligibility information included in this application for the ____________ school year is true. If at any point the school's status changes, I will report this information to the Department of Education, Office of Independent Education and Parental Choice.

______________________________ School Administrator (Printed Name)

_______________ Date

______________________________ School Administrator Signature

STATE OF FLORIDA COUNTY OF___________

The foregoing instrument was acknowledged before me this ______ day of ______________, 20__,

by____________________________ (name of person acknowledging).

Personally Known Or Produced Identification Identification Produced ___________________________________

NOTARY SEAL

____________________________________________ (SIGNATURE OF NOTARY)

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____________________________________________ (PRINTED NAME OF NOTARY)

Application # ______________

2012-2013 CONFIDENTIAL FAMILY INCOME SURVEY

*FTC Scholarship families are exempt from this survey.

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Page 2 of 2

2012-2013 FEDERAL INCOME GUIDELINES Effective July 1, 2012 to June 30, 2013

Household Size

-1-2-3-4-5-6-7-8For each additional family member, add

Annual

20,665 27,991 35,317 42,643 49,969 57,295 64,621 71,947

7,326

Reduced Prices Meals

Month

1,723 2,333 2,944 3,554 4,165 4,775 5,386 5,996

Twice Per Month 862 1,167 1,472 1,777 2,083 2,388 2,693 2,998

Every Two Weeks 795 1,077 1,359 1,641 1,922 2,204 2,486 2,768

611

306

282

Week

398 539 680 821 961 1,102 1,243 1,384

141

Household Size

-1-2-3-4-5-6-7-8For each additional family member, add

Annual

14,521 19,669 24,817 29,965 35,113 40,261 45,409 50,557

5,148

Month

1,211 1,640 2,069 2,498 2,927 3,356 3,785 4,214

429

Free Meals

Twice Per Month 606 820 1,035 1,249 1,464 1,678 1,893 2,107

215

Every Two Weeks 559 757 955 1,153 1,351 1,549 1,747 1,945

198

Week

280 379 478 577 676 775 874 973

99



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