Austin ISD Income Verification Form *Confidential*

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Complete 1 Application Per Household

Student(s) Last Name *

Student(s) First Name *

Austin ISD is required to collect and report the socioeconomic status of each student to the Texas Education Agency for purposes of the annual state accountability ratings and for federal reporting. Please note that this form is not sent to the Texas Education Agency and that the income levels indicated for your family are not reported to the Texas Education Agency. Only the Economic Disadvantaged status of each student as determined by the information provided is reported to the Texas Education Agency.

Do you receive Supplemental Nutrition Assistance (SNAP)? *

Yes

Other:

Do you receive Temporary Assistance to Needy Families (TANF)? *

Yes

Other:

How many members are in the household (include all adults and children)? *

TOTAL YEARLY INCOME BEFORE DEDUCTIONS OF ALL HOUSEHOLD MEMBERS (Include wages, salary,welfare payments, child support, alimony, pensions, Social Security, worker’s compensation, unemployment and all other sources of income, before any type of deductions) *

SIGNATURE Please check one of the following two boxes as appropriate.In accordance with the provisions of the Protection of Pupil Rights Amendment (PPRA) no student shall be required, aspart of any program funded in whole or in part by the U.S. Department of Education, to submit to a survey, analysis, orevaluation that reveals information concerning income (other than that required by law to determine eligibility for participation in a program or for receiving financial assistance under such program), without the prior written consent of the adult student, parent or legal guardian. *

I certify that all the information on this form is true and that all income is reported. I understand the school will receive federal funds and will be rated for accountability based on the information I provide.

I choose not to provide this information. I understand that the school’s disbursement of federal funds and accountability rating may be affected by my choice. If I’m a parent of a PreK student, I understand that by choosing not to provide this information it is possible that my child may no longer qualify for PreK services based on income.

Required

Parent Name *

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