Last Name Other Income

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					                                                                                                                          Crowley County Online Academy
                                                                                                                       Crowley County School District RE1-J
                                                                                                                                                     P.O. Box 338
                                                                                                                                                Ordway, CO 81063
                                                                                                                            Phone: 719-267-3117 Fax: 719-267-3130
                                                         FAMILY ECONOMIC DATA SURVEY
Please complete a separate survey for each of your children attending this school. Complete the information, sign your name, and return the
survey to the school. Completion of this survey is voluntary, but may assist the school in receiving additional State/Federal funding, or other
benefits for your child.
1. PRIMARY HOUSEHOLD (STUDENT RESIDES AT)
Last name of parent or guardian:
Address 1:
Address 2:
City:                                                 State:          Zip:                 Phone:
2. STUDENT PERSONAL INFORMATION
First:                                 Last Name:                                                   School:                                    Grade:
3. ECONOMIC INFORMATION
Food Stamp Case Number:

Note: If you entered a food stamp case number above please skip to step 6.
4. RELATIONSHIP INFORMATION
Is this student a foster child?        Yes            No

If this is a child who is the legal responsibility of a welfare agency or court, list the amount of the child’s personal use monthly income:
Enter “0” if the child has no personal use income; Skip to Part 5
5. HOUSEHOLD INCOME

Total Household Gross Income from Last Month (List every one in household)
                    Last Name                                                First Name                                 Gross Income            Other Income




6. SIGNATURE

Please print and sign this form. This must be signed by an adult household member.

I certify (promise) that all information on this application is true and that all income is reported. I understand that the school may get State
or Federal funds based on the information I give. I understand that school officials may verify (check) the information.




Signature of Adult                                                                                                        Date
SCHOOL USE ONLY. DO NOT FILL OUT THIS SECTION.

Monthly Income Conversion: Weekly X 4.33, Every 2 Weeks X 2.15, Twice A Month X 2
Monthly Income:                                             Household Size:                                   FS:

Eligibility:      Yes                  Type                                                   No
Date Withdrawn:                                                                Date Survey Declined:




Signaure of Determining Official                                                                                          Date