Alternate Household Income Form (2026-2027)

2026-27 Alternate Household Income Form

Your child's school participates in the Community Eligibility Provision, which means all students qualify for free meals. However, to determine eligibility to receive additional benefits beyond free meals for your child(ren) and school, please complete this alternate income form.
Section 1: Student Information
Instructions: List all students in the household, through grade 12. If any child you are listing is a foster child; homeless, migrant, or runaway; or attends Head Start, please check the appropriate box.

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Household Students

Rows	First Name	Last Name	Grade	School Child Attends	Foster	** H, M, or R	Head Start
1
2
3
4
5
6
7
8
9
10

Please List all Household Students here
** Homeless, Migrant, or Runaway
Section 2: Household Income
Instructions: Your household size is the total number of people, including all children and adults, related and un-related, that live in a single dwelling and share income and expenses. Please mark
your household size and then select the applicable yearly total household income range under the number of people in the household. Make sure to include all of the following income sources: work,
welfare, child support, alimony, pensions, retirement, Social Security, SSI, VA benefits, child income and/or all other income. The amount should be before any deductions for taxes, insurance,
medical expenses, child support, etc.
Household Size? Total number of people, including all children and adults, related and un-related, that live in a single dwelling and share income and expenses.
You indicated that your household size is 1 person. What is your total household yearly income before any deductions such as taxes, insurance, medical expenses, child support, etc.
You indicated that your household size is 2 people. What is your total household yearly income before any deductions such as taxes, insurance, medical expenses, child support, etc.
You indicated that your household size is 3 people. What is your total household yearly income before any deductions such as taxes, insurance, medical expenses, child support, etc.
You indicated that your household size is 4 people. What is your total household yearly income before any deductions such as taxes, insurance, medical expenses, child support, etc.
You indicated that your household size is 5 people. What is your total household yearly income before any deductions such as taxes, insurance, medical expenses, child support, etc.
You indicated that your household size is 6 people. What is your total household yearly income before any deductions such as taxes, insurance, medical expenses, child support, etc.
You indicated that your household size is 7 people. What is your total household yearly income before any deductions such as taxes, insurance, medical expenses, child support, etc.
You indicated that your household size is 8 people. What is your total household yearly income before any deductions such as taxes, insurance, medical expenses, child support, etc.
You indicated that your household size is 9 people. What is your total household yearly income before any deductions such as taxes, insurance, medical expenses, child support, etc.
You indicated that your household size is 10 people. What is your total household yearly income before any deductions such as taxes, insurance, medical expenses, child support, etc.
You indicated that your household size is 11 people. What is your total household yearly income before any deductions such as taxes, insurance, medical expenses, child support, etc.
Section 3: Contact Information and Adult Signature

"I certify (promise) that all information on this form is true, and that all income is reported:"
Name of person completing this form

First NameLast Name
Address

Street Address

Apt. #

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signature
Should be Empty:

2026-27 Alternate Household Income Form

Section 1: Student Information

Section 2: Household Income

Section 3: Contact Information and Adult Signature