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

Thank you so much for your support and cooperation.


Elizabeth M. Hamilton
St. Jane de Chantal
                                              FAMILY SURVEY
                                             School Year 2012-2013

Child’s Name:                                             Grade Level:
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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