CONFIDENTIAL FAMILY INCOME AND INFORMATION
We are required by the U.S. Department of Education to obtain family income and other eligibil-
ity information from all participants served by the Upward Bound program. Please complete the
STUDENT’S FULL NAME ______________________________________________________
GRADE ____________________
SCHOO
L__________________________________________________________________
Student is a participant in the school free lunch program Yes No
A biological/adoptive parent (with whom the child lives) graduated from a four-year college. Yes No
PARENT’S NAME NAME OF COLLEGE/UNIVERSITY DEGREE EARNED YEAR
____________________ ____________________________ ________________ ______
NUMBER OF PEOPLE LIVING IN HOUSEHOLD ___________________
DID THE FAMILY FILE A FEDERAL INCOME TAX REPORT LAST YEAR? YES NO
(If yes, complete section A. If no, complete section B.)
SECTION B
Please provide documentation of
income sources i.e. award letter,
etc. List all sources of income below:
$__________FOOD STAMPS
$__________K-TAP
$__________CHILD SUPPORT
$__________RETIREMENT
$__________UNEMPLOYMENT
$__________DISABILITY
$__________SOCIAL SECURITY
$__________VETERAN BENEFITS
TOTAL INCOME FOR LAST YEAR:
$______________
Parent/Guardian Signature________________________________ Date_________________
SECTION A
______Yes, a copy of last year’s federal income tax report will be
included with this application.
Taxable income from form 1040 (line 11b)
Family Size Taxable Income
____1 ____$0-$19,140
____2 ____$19,141-$25,860
____3 ____$25,861-$32,850
____4 ____$32,851-$39,300
____5 ____$39,301-$46,020
____6 ____$46,021-$52,740
____7 ____$52,741-$59,460
____8 ____$59,461-$66,180
Do you expect any major decrease in your family income this year? Yes (attach written explanation) No
I verify by signing this document and submitting the requested documentation that the information I have provided is
Upward Bound program at SCC.
