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Alternate Income Form
Free/Reduced Bus Pass Application 2023/2024
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* Indicates required question
Student's First Name
*
Your answer
Student's Last Name
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Your answer
Student's DOB
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MM
/
DD
/
YYYY
School of Attendance
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Choose
Beechwood Elementary
Hermosa Elementary
Rolling Hills Elementary
Ladera Vista Jr. High
Parks Jr. High
Student Grade
*
Choose
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
Student ID Number
*
Your answer
Based on your household size, please refer to the appropriate box to see if your monthly household income is within the range displayed for Category 1, 2 or 3. (MUST MATCH THE AIR FORM)
If household size is greater than 8, list household size and total monthly income:
Household Size
*
Choose
1
2
3
4
5
6
7
8
Total Monthly Household Income (MUST MATCH AIR FORM)
*
Your answer
I certify (promise) that the information provided on this form is true and that I included all income. I understand that the school may receive state and federal funds based on the information I provide.
*
Choose
Yes
No
Name of Adult Household Member Completing Form:
*
Your answer
Signature (Electronic):
*
Your answer
Date:
*
MM
/
DD
/
YYYY
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