[Use School/School District Letterhead]
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E-Rate Family Survey - 2008/2009
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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 _________
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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 |
$ 19,240 |
$ 1,604 |
$ 370 |
2 |
$ 25,900 |
$ 2,159 |
$ 499 |
3 |
$ 32,560 |
$ 2,714 |
$ 627 |
4 |
$ 39,220 |
$ 3,269 |
$ 755 |
5 |
$ 45,880 |
$ 3,824 |
$ 883 |
6 |
$ 52,540 |
$ 4,379 |
$ 1,011 |
7 |
$ 59,200 |
$ 4,934 |
$ 1,139 |
8 |
$ 65,860 |
$ 5,489 |
$ 1,267 |
For each additional
family member add |
$ 6,660 |
$ 555 |
$ 129 |
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| Is your family's income equal to or less than any of the amounts listed next to
the number you circled? |
Yes ____ |
No ____ |
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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 ____ |
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Is your family eligible for food stamps?
| Yes ____ |
No ____ |
| Is your family eligible for medical assistance under Medicaid? |
Yes ____ |
No ____ |
| Does your family receive Temporary Assistance for Needy Families (TANF)? |
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 ____ |
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II. If you answered yes to any of the preceding questions, 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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General Forms> Sample Survey
