Income Verification for Fee Waiver 2023-2024

Eligibility Status Information

Household Size*

Please provide the total number of people in your household. (You must include yourself and all children/adults living in your household, related or not.)

Household Income*

Please provide the total annual income for all people in the household before any deductions for taxes, insurance, medical expenses, child support, etc.

2023-2024 Federal Income Guidelines Chart

Household Size	Yearly	Monthly	Twice per Month	Every Two Weeks	Weekly
1	26,973	2,248	1,124	1,038	519
2	36,482	3,041	1,521	1,404	702
3	45,991	3,833	1,917	1,769	885
4	55,500	4,625	2,313	2,135	1,068
5	65,009	5,418	2,709	2,501	1,251
6	74,518	6,210	3,105	2,867	1,434
7	84,027	7,003	3,502	3,232	1,616
8	93,536	7,795	3,898	3,598	1,799
Each additional person:	9,509	793	397	366	183

Student Information

Please list ALL STUDENTS in your household.

Student 1 Name*

First Last

Student 1 School*

Student 1 Grade*

Do you have a second student?*

Yes

Student 2 Name*

First Last

Student 2 School*

Student 2 Grade*

Do you have a third student?*

Yes

Student 3 Name*

First Last

Student 3 School*

Student 3 Grade*

Do you have a fourth student?*

Yes

Student 4 Name*

First Last

Student 4 School*

Student 4 Grade*

Do you have a fifth student?*

Yes

Student 5 Name*

First Last

Student 5 School*

Student 5 Grade*

Do you have a sixth student?*

Yes

Student 6 Name*

First Last

Student 6 School*

Student 6 Grade*

Do you have a seventh student?*

Yes

Student 7 Name*

First Last

Student 7 School*

Student 7 Grade*

Confirmation and Acknowledgement

Parent/Guardian Name*

First Last

Phone*

Address*

Street Address Address Line 2 City ZIP Code

Acknowledgement*

By clicking "I agree" below, I certify that I am the parent/guardian of the student(s) listed on this income verification form. I certify that all information on this form is true and that all income is reported if required.

I agree to the terms of the options I have selected in this form and understand that, if approved, my household income eligibility status will be used to determine fee waiver eligibility.

I agree