Sample Income Survey

[Use School/School District Letterhead]


[Insert Date]

Dear Parents,
 


You may know that the [Insert School/School District name] has been participating in the E-rate program for the past [xx] years. The E-rate program is a Federal program which provides schools and libraries across the country with substantial discounts on their technology services.

These discounts reduce the costs of our telephone service, Internet access, and the internal connections we use to build and maintain the computer networks that link our classrooms. The size of the discounts which we receive is based the income level of our student’s families. Our local public library also benefits since it shares our discount rate. Discounts also save the district and taxpayers a substantial amount of money.

We need your help qualifying for the largest discount allowable by providing us with some very general information. Please take a minute to fill out and return the attached survey to [Insert contact person’s name/address] before [Insert date]. This information will remain confidential and will be reported only as a total group, not by individual families, and will not be used for any purpose other than E-rate.

The income guidelines on the attached survey are the same as those used for participation in the Free and Reduced Lunch Program. However, since responses to the survey will be kept confidential, answering yes to any of the questions on the attached form will not make your children eligible to receive Free or Reduced price lunches. Instead, if you have children you would like to enroll in the Free and Reduced Lunch Program, please contact [Insert contact person’s name/address/phone number].

Thank you for your participation in helping [Insert School/School District name] stretch its resources to best serve all our students. If you have any questions, please call our office at [Insert telephone number].


Thank you,



[Name]
[Title]

[Use School/School District Letterhead]

 E-Rate Family Survey – 2017/2018

 Please complete and return the survey below. It is important that you return this form to us even if your income does not meet any of these criteria in order for the survey to be considered a valid measure.


(Please Print)

Family Name _______________________________________________________________

Street Address ______________________________________________________________

City ____________________________ State ____________ Zip _______________

  1. Please attempt to answer the questions listed below. Skip any questions you don't know the answer to.

Circle the number of people in your family on the chart below, including all children:

Family Size (circle one)

Annual Income

Monthly Income

Weekly Income

1

$ 22,311

$ 1,860

$ 430

2

$ 30,044

$ 2,504

$ 578

3

$ 37,777

$ 3,149

$ 727

4

$ 45,510

$ 3,793

$ 876

5

$ 53,243

$ 4,437

$ 1,024

6

$ 60,976

$ 5,082

$ 1,173

7

$ 68,709

$ 5,726

$ 1,322

8

$ 76,442

$ 6,371

$ 1,471

For each additional
family member add

+ $ 7,733

+ $ 645

 + $ 149

 

Is your family's income equal to or less than any of the amounts listed next to the number you circled?

Yes ______

No ______

Are your children eligible for the NSLP (National School Lunch Program) which provides free or reduced lunches, breakfasts, snacks or milk at their school(s)?

Yes ______

No ______

Is your family eligible for food stamps?

Yes ______

No ______

Is your family eligible for medical assistance under Medicaid?

Yes ______

No ______

Does your family receive Supplementary Security Income (SSI)?

Yes ______

No ______

Does your family receive housing assistance (section 8)?

Yes ______

No ______

Does your family receive home energy assistance (LIHEAP)?

Yes ______

No ______

 II. To validate this survey, please list the names of all school children living in your home, including which school they attend.

Name of Child

School

Grade

__________________________________________

__________________________________________

_______

__________________________________________

__________________________________________

_______

__________________________________________

__________________________________________

_______

__________________________________________

__________________________________________

_______

__________________________________________

__________________________________________

_______

__________________________________________

__________________________________________

_______

__________________________________________

__________________________________________

_______

Return completed survey to: [Insert contact person's name and address]. Remember, the results of this survey will be kept confidential, you will have to contact [Insert contact person's name/address/phone number] if you wish to enroll any of your children into the Free and Reduced Lunch Program.

Call [Insert contact person's name and phone number] if you have any questions about filling out this form.