Part 1 ~ List all members living in your household including students
Part 2 ~ If the family receives SNAP/TANF this is a 13 digit number. Please do not put medical numbers. If you receive medical, you must fill out income section.
Part 4 ~ If applying, fill in information for anyone in household who receives income. This is confidential information and will not be shared. Any household that does not think they qualify, please mark NOT APPLYING across this section.
Part 5 ~ If you are eligible for free/reduced you may have fees waived. Please check and sign. If you are interested in information for SNAP or All Kids, please check and sign.
Part 6 ~ All applications must be signed.