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Confidential Family Income Survey
Confidential Family Income Survey for 2022-2023
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* Indicates required question
Student ID (Type 000000 if unknown)
*
Your answer
Student First Name
*
Your answer
Student Last Name
*
Your answer
Student Date of Birth
*
MM
/
DD
/
YYYY
If you have additional students at Chaffey, please write their name, date of birth and ID (if you know it).
*
Your answer
Student Grade
*
9th
10th
11th
12th
Street Address
*
Your answer
Apt. #
Your answer
City
*
Your answer
Zip Code
*
Your answer
Phone number
*
Your answer
Adult Signature (adult completing the form - please type your name)
*
Your answer
Today's Date
*
MM
/
DD
/
YYYY
Does the student participate in the foster program?
*
Yes, you have completed the form. You do not need to complete the income information questions.
No. Please continue and answer the remaining household income questions.
Do any household members have a
FDPIR case number
?
If
yes
,
please write the case number below. You do not need to answer the household income questions below.
If
no
,
please complete the remaining questions about household income.
Your answer
What is the total number of household members?
Your answer
Income amount $
Your answer
Is the income amount:
Weekly
Bi-weekly
Monthly
Clear selection
Source of income (check all that apply):
*
Earnings from work
Public assistance
Pension
Retirement
Child support
Social security
Unemployment
Other
Required
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