SCHOOL NAME DATE INCARNATE WORD ACADEMY
ANNUAL INCOME ELIGIBILITY PARENT SURVEY
Erate Funding Year 25 - 2022-2023
RETURN IN A SEALED ENVELOPE TO SCHOOL PRINCIPAL
Please complete and return the survey below. 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 worked each year to determine your “Annual Gross Income.”
PLEASE CIRCLE HOUSEHOLD SIZE IN TABLE BELOW:
Household Size Annual Month Twice Per Month Every Two Weeks Week
1 $23,606 $ 1,968 $984 $ 908 $454
2 31,894 2,658 1,329 1,227 614
3 40,182 3,349 1,675 1,546 773
4 48,470 4,040 2,020 1,865 933
5 56,758 4,730 2,365 2,183 1,092
6 65,046 5,421 2,711 2,502 1,251
7 73,334 6,112 3,056 2,821 1,411
8 81,622 6,802 3,401 3,140 1,570
For each additional family
member, add:
+ 8,288 + 691 + 346 + 319 + 160
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.
NAME OF CHILD NAME OF SCHOOL GRADE LEVEL
Example: Family Size Annual Income
4 $
48,4705
81
622
