E-Rate Program Family Survey for Funding Year 2021
Our School will use the information on this Survey to maximize our outside funding, which will help to provide a better education for your children. For example, E-Rate fund will fund part of our Internet bills and help fund improvements to our wireless network allowing more money to be used for educational programs and resources for students.

Please complete and return this survey.  It is VERY important to return this form to us even if your income does not meet any of these criteria for the school’s survey to be considered a valid measure for the school.

ALL INFORMATION GATHERED IN THE FORM WILL BE KEPT STRICTLY CONFIDENTIAL
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Family Name: *
These sections must be completed by head of household or designee:
Indicate the number of people in your family, including ALL children: *
B. Using the chart, please try to answer the questions. Skip any question you don't know the answer to:
1. Is your income equal to or less than the amount listed by the family size you indicateD?
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2. Are your children eligible for free or reduced lunches, breakfasts, snacks or milk at their school(s)?
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3. Is your family eligible for the Supplemental Nutrition Assistance Program (SNAP) - food stamps?
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4. Does your family qualify for medical assistance under Medicaid?
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5. Is your family receiving Supplementary Security (SSI)?
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6. Does your family receive housing assitance (section B)?
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7. Does your family receive home energy assistance  (LIHEAP)?
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C. Please list all students in your household that attend school in this format: Name of Child, Grade in fall 2020, school attended *
D. Certification:  I certify that the above information is, to the best of my knowledge, true and complete.  Please add your name and date in the box  below. *
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