Wheels of Learning Back-to-School Event

Back-to-School Supply Initiative: Students Grades K-12

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* 1. Personal Information

Date:

Name:

Phone:

Address:

Zip Code:

Email:

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* 2. Full name of students

Student 1

Student 2

Student 3

Student 4

Student 5

Student 6

Student 7

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* 3. Student Information

	Age	Grade	School Name	School Districts
Student 1	Student 1 Age menu	Student 1 Grade menu	Student 1 School Name menu	Student 1 School Districts menu
Student 2	Student 2 Age menu	Student 2 Grade menu	Student 2 School Name menu	Student 2 School Districts menu
Student 3	Student 3 Age menu	Student 3 Grade menu	Student 3 School Name menu	Student 3 School Districts menu
Student 4	Student 4 Age menu	Student 4 Grade menu	Student 4 School Name menu	Student 4 School Districts menu
Student 5	Student 5 Age menu	Student 5 Grade menu	Student 5 School Name menu	Student 5 School Districts menu
Student 6	Student 6 Age menu	Student 6 Grade menu	Student 6 School Name menu	Student 6 School Districts menu
Student 7	Student 7 Age menu	Student 7 Grade menu	Student 7 School Name menu	Student 7 School Districts menu

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* 4. Total Number of Household Members

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* 5. Total Annual Gross Household Income

$40,080 - 1 Person

$45,780 - 2 Persons

$51,480 - 3 Person

$57,180 - 4 Person

$61,800 - 5 Person

$66,360 - 6 Person

$70,920 - 7 Person

$75,480 - 8 Person

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* 6. Eligibility Criteria/Proof of Income - Paycheck Stubs are not accepted

2024 Tax Return

Federal Pell Grant

Medicaid or Medical Assistance (Bring a Document that says "MA or "Medical Assistance" on it )

Section 8 or other Federal Public Housing Assistance ( A copy of lease in required)

SNAP (Food Stamps) (Benefit Letter)

Supplemental Security Income (SSI) (Benefit Letter)

Temporary Assistance for Needy Families (TANF) (A 2025 dated letter showing current eligibility is required)

WIC - Women infants and Children (Benefit Letter)

Please submit the proof of income documents to OIC@topeka.org or bring them in person to the Cyrus K. Holliday Building located at 620 SE Madison Avenue.

Wheels of Learning Back-to-School EventBack-to-School Supply Initiative: Students Grades K-12

Question Title

* 1. Personal Information

Question Title

* 2. Full name of students

Question Title

* 3. Student Information

Question Title

* 4. Total Number of Household Members

Question Title

* 5. Total Annual Gross Household Income

Question Title

* 6. Eligibility Criteria/Proof of Income - Paycheck Stubs are not accepted

Wheels of Learning Back-to-School Event

Back-to-School Supply Initiative: Students Grades K-12