SCHOOL NAME DATE ARCHDIOCESE OF GALVESTON HOUSTON
ANNUAL INCOME ELIGIBILITY PARENT SURVEY
Erate Funding Year 23 - 2020-2021
RETURN IN A SEALED ENVELOPE TO SCHOOL PRINCIPAL
Please complete and return the survey below. In order for this survey to be considered a valid measure, the survey must be returned
to the principal even if your income does not meet any of the criteria. The purpose of this survey is to collect data that will be
used to determine the school’s federal funding allocation. Use the chart below to find your family size. Family size may include a foster
child, an emancipated youth or a special education student over age 18. If you are paid on a weekly or monthly basis, please multiply
that amount by the number of weeks or months actually worked each year to determine your “Annual Gross Income.”
PLEASE CIRCLE HOUSEHOLD SIZE IN TABLE BELOW:
For each additional family
member, add:
+ 8,177 + 682 + 341 + 315 + 158
Please circle your answer
1. If your family income is the same or less than the amount shown on the chart beside your family size,
circle yes. If more than the amount shown, circle NO and move to the bottom portion. YES NO
2. Is your family eligible for food stamps? YES NO
3. Are you receiving public assistance? Food stamps, or TANF (formerly AFDC) YES NO
4. Are any of your children eligible for the "Medicaid" program? YES NO
5. Are you receiving full scholarship based on need for your child/children? YES NO
6. Are you receiving free or reduced tuition for your child/children? YES NO
7. Does your family live in a housing project or have poor housing conditions? YES NO
8. Do you have an unusual financial burden? If yes, please explain: (If necessary use back of page) YES NO
FAMILY NAME (PRINT):
____________________________________________________________________
FAMILY ADDRESS:
______________________________________________________________________________________________________
PUBLIC SCHOOL DISTRICT IN WHICH YOU RESIDE: _________________________________________
List the name of all school age children living in your home, including which school they attend and their grade level.
Example: Family Size Annual Income
4 $46,435
