PART 1:

CHILD(REN) IN SCHOOL

LAST NAME

FIRST NAME

SCHOOL

GRADE

CHECK WHICH CHILDREN WILL ATTEND AIA CLASSES √

1.

2.

3.

PART 2:

FOSTER CHILD

PERSONAL USE INCOME

SCHOOL

GRADE

NAME:

PART 3:

HOUSEHOLDS RECEIVING FOOD STAMP or AID TO DEPENDENT CHILDREN (ADC)

FOOD STAMP #_________________________________________

TEMPORARY ASSISTANCE TO NEEDY FAMILIES (TANF)

ADC/TANF#_____________________________________________

PART 4:

HOUSEHOLD MEMBERS AND TOTAL INCOME

EARNINGS FROM WORK BEFORE DEDUCTIONS (Weekly, monthly, yearly)

CHILD SUPPORT, ALIMONY

(Weekly, monthly, yearly)

PAYMENTS FROM PENSION OR RETIREMENT

(Weekly, monthly, yearly)

OTHER INCOME

(Weekly, monthly, yearly)

NAME:_____________________

NAME:____________________

NAME:_____________________

PART 5:

SIGNATURE AND SS#

SIGNATURE:________________

NAME:_____________________

MAILING ADDRESS:________________________________

SOCIAL SECURITY #_____________

HOME PHONE:

WORK PHONE:

CELL PHONE: