Fee Waiver Application Form (Grades 7-12) (Page 2 of 2) in pdf

Section B: INCOME VERIFICATION FOR ALL HOUSEHOLD MEMBERS (Required for students who do not qualify based on a special category.)

LIST ALL INCOME BEFORE DEDUCTIONS IN THE APPROPRIATE COLUMN(S) ON SAME LINE AS RECEIVER.

Convert to monthly income: (weekly) multiply by 4.33; (every two weeks) multiply by 26 divide by 12; (twice a month) multiply by 2; and (annually) divide by 12

The last income tax return or the last three pay stubs, or both, if available, of each household member are required to be attached to this form.

NAME

Earnings from work

Pension/Retirement

Welfare, alimony

Other income

Total by Adult

Last

First

M.I.

(before deductions)

Social Security

child support

2nd job, etc.

Monthly

(also known

as)

Job 1 Monthly

Monthly

Income

Total number of ALL PEOPLE living in household _________________

Section C. EXAMPLES OF INCOME

Pension/Retirement

Welfare, Alimony

Other

Earnings from Work

Social Security

Child Support

Income

Wages, salaries and tips, strike

Pensions, supplement,

TANF payments,

Disability benefits; cash withdrawn from savings;

benefits, unemployment comp.,

security income,

welfare payments,

interest & dividends; income from estates, trusts, and

workers' comp, nKet income from

retirement payments,

alimony, and child

investments, regular contributions from persons not

self-owned business or farm

Social Security Income

support payments

living in the household; net royalties and annuities;

(including SSI a child

net rental income; any other income

receives)

Section D. INCOME ELIGIBILITY GUIDELINES July 1, 2016 to June 30, 2017

Household Size

Yearly

Monthly

Twice Per Month

Every Two Weeks

Weekly

15,444

1,287

644

594

297

20,826

1,736

868

801

401

26,208

2,184

1,092

1,008

504

31,590

2,633

1,317

1,215

608

36,972

3,081

1,541

1,422

711

42,354

3,530

1,765

1,629

815

47,749

3,980

1,990

1,837

919

53,157

4,430

2,215

2,045

1,023

For each additional

5,408

451

226

208

104

family member, add:

In lieu of income verification, attach supporting documents to this form for each special category that applies. For TANF (financial assistance or food stamps)

attach a letter of decision covering the current period from Workforce Services.

For SSI (QUALIFIED CHILD WITH DISABILITIES), attach the benefit verification letter from Social Security. For State custody or foster care, provide the "youth in

custody required intake form" and/or "school enrollment letter" provided by the case worker from DCFS or Juvenile Justice Department.

This form and all supporting documents will be destroyed after the approval process is complete.

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