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Sample Survey
2016-2017 School Year

To Cover Letter   >>

 

[Use School/School District Letterhead]

 

E-Rate Family Survey — 2016/2017

 

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 _________

 

I. 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 $ 21,978 $ 1,832 $ 423
2 $ 29,637 $ 2,470 $ 570
3 $ 37,296 $ 3,108 $ 718
4 $ 44,955 $ 3,747 $ 865
5 $ 52,614 $ 4,385 $ 1,012
6 $ 60,273 $ 5,023 $ 1,160
7 $ 67,951 $ 5,663 $ 1,307
8 $ 75,647 $ 6,304 $ 1,455
For each additional
family member add
+ $ 7,696 + $ 642 + $ 148


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.

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