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.

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* 1. Family Name

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* 2. Street Adress

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* 3. City/State/Zip

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* 4. Please attempt to answer the questions listed below. Skip any questions you don't know the answer to.

  Family Size
Choose the number of people in your family in column one on the cart below, including all children:

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* 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

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* 6. For the following questions, please check yes or no

  Please choose answer
Is your family's income equal to or less than any of the amounts listed next to the number you circled?
Are your children eligible for the NSLP (National School Lunch Program) which provides free or reduced lunches, breakfast, snacks or milk at the school?
Is your family eligible for medical assistance under Medicaid?
Does your family receive Supplemental Security Income (SSI)?
Does your family receive housing assistance (Section 8)?
Does your family receive home energy assistance (LIHEAP)?

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* 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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