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.

* 1. Family Name

* 2. Street Adress

* 3. City/State/Zip

* 5. Please use the attached chart to answer question 6
Family Size Annual Income Monthly Income Weekly Income
1 $21,257 $1,772 $409
2 $28,694 $2,392 $552
3 $36,131 $3,011 $695
4 $43,568 $3,613 $838
5 $51,005 $4,251 $981
6 $58,442 $4,871 $1,124
7 $65,879 $5,490 $1,267
8 $73,316 $6,110 $1,410
for each additional family member add:                             $7,437      $620         $144

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

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