Eligibility Change Form for Families Already Found Eligible
Student Name ____________________________________________________ Date of Birth_______________________
Parent/Guardian Name____________________________________________ Phone Number______________________
Please check one:
_____
My income has changed due to a change in employment hours. Please list Employer name and contact
phone number below for verification or provide proof of income change as provided by your employer:
_________________________________________________________________________________________________
_____
My income has changed due to an end in employment. Please list your former Employer's name and
contact info below for verification or provide proof of employment ending as provided by former
employer.
_________________________________________________________________________________________________
_____
My income has changed due to a change in support services. Please list the source of financial assistance that
ended or began and provide proof of assistance ending/starting as provided by the organization.
_________________________________________________________________________________________________
_____
My household number has changed. Please list the changes including specification of those supported by
your income
.
_________________________________________________________________________________________________
_____
My housing status has changed. Please list the changes and include proof of this status change
.
_________________________________________________________________________________________________
By signing below, you verify that the information provided above is complete and truthful. I understand that my
child may be withdrawn from enrollment/attending if any information I provided proves to be false
_______________________________________________________________________________
(Parent/Guardian signature) (Date)
_______________________________________________________________________________
(Parent/Guardian signature) (Date)
Return this form along with documentation of your change to PSDECE@psdschools.org, or mail it to Fullana
at 220 N. Grant Ave., Fort Collins CO 80521
