1. ALL HOUSEHOLD MEMBERS. List all people living in the household including all children. List all current household income, where applicable, before expenses and deductions for taxes, etc., and how often it is paid: weekly (wk), every two weeks (bi-wk), twice a month (twice), or monthly (mo). If your income varies, write the amount you usually earn. Use additional paper if needed. Note: Parents/Guardians should submit one month of consecutive pay stubs and they must be submitted within 30 days of this application.
2. SIGNATURE. I certify that all the above information is true and that all income is reported. I understand that this information is being given for the school’s receipt of state funds; that school officials may verify the information. Falsification of any information submitted may be cause for rejection of this application or removal from the program after placement.
3. SIGNATURE OF Provider Official Reviewing Documentation