Early Learning Academy
Income Verification Form
Regional Office of Education #08
Early Learning Academy
27 S. State Ave., Suite 101, Freeport, IL 61032
Phone: 815.599.1408 Fax: 815.297.9032
www.roe8.com
Updated January 2021
_______________________________ _____________________
Student’s First Name Student’s Last Name
P
reschool for All (Early Learning Academy) is a need-based program and as such, the serving school
district is required to verify and copy physical proof of your household income based on the following
federal guidelines, using 1 or more of the following sources:
*Please Highlight the appropriate house hold income range.
First choose the number of people living in
the household and then follow the line over and choose the
income range that is closest to the household income. Example: Bob has a family of 6 and he and his
significant other make $37,000 combined income. Bob would go to line # 6 and Highlight the
35,581-71,160 range on the chart.
I, t
he parent or legal guardian of verify, that the above
information is true and correct. I understand that if my Family or Household income exceeds
the above listed amounts, my child may not qualify for Preschool for All unless other needs
are indicated during the screening process.
_______________________________________ ____________________________
Parent/Guardian Signature Date
2 Most Recent Pay Stubs, Consecutive
Wages and Tax Statement (Most Recent W-2)
Medicaid Card; In Parent/Guardian Name
CCAP; Child Care Assistance Program Documentation
Signed written statement from the family verifying no income
click to sign
signature
click to edit
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