St. Jane Frances de Chantal School 9525 Old Georgetown Road Bethesda, Maryland 20814 Date: September 4, 2012 Dear Catholic School Parent: I am writing to ask for your cooperation in completing the Archdiocese of Washington’s Family Survey for each student that will help us secure maximum federal and state educational services for the children in our Catholic schools. Please complete the information on the attached Family Survey and return the form to the school office. The information requested on the form will remain confidential, and must be provided to our school office no later than Friday, September 14, 2012. Providing us with the information requested on the enclosed form will help us increase the educational and technology services we are able to provide to our children, such as reading programs and summer school. Your tax dollars are paying for these programs, please help us keep them. Additionally, many foundations and grants, who are potential benefactors to our school, require an overview of our school needs as a part of applying to their programs. This data directly impacts the amount of funding we receive. Thank you so much for your support and cooperation. Sincerely, Elizabeth M. Hamilton Principal St. Jane de Chantal FAMILY SURVEY School Year 2012-2013 Child’s Name: Grade Level: Address: City/State: Zip: Please indicate the name of the public school your child would attend: ________________________________________________________________________ A. Is your family eligible for School Nutrition Programs? Please circle your household size in the chart below. 2012–2013 Income Eligibility Guidelines ANNUAL HOUSEHOLD HOUSEHOLD SIZE INCOME 1 0–$20,665.00 2 $20,666.00–$27,991.00 3 $27,992.00–$35,317.00 4 $35,318.00–$42,643.00 5 $42,644.00–$49,969.00 6 $49,970.00–$57,295.00 7 $57,296.00–$64,621.00 8 $64,622.00–$71,947.00 9 $71,948.00–$79,273.00 10 $79,274.00–$86,599.00 For each additional family member, add $7,326.00 (Note that household size is equal to the total number of adults and children living in your home. This may include a foster child, an emancipated youth or a special education child over the age of 16.) 1) Is your family income LESS than the corresponding amount in column? Yes _____ No _____ B. Is your family receiving public assistance payments or welfare benefits. (ex. TANF, GC) Yes No C. Is your child eligible to receive medical assistance under the Medicaid Program? Yes No D. Is your family eligible for the Supplemental Nutrition Assistance Program? (SNAP) (formerly Food Stamps) Yes No Please return this form to the school office no later than Friday, September 14, 2012.
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