Haledon Public School

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Household Information Survey 2020-2021

1. List all who live in the household: Names (Last Name, First Name, Birthdate, Grade(if applicable ) *

2. List all who live in the household: Names (Last Name, First Name, Birthdate, Grade(if applicable )

3. List all who live in the household: Names (Last Name, First Name, Birthdate, Grade(if applicable )

4. List all who live in the household: Names (Last Name, First Name, Birthdate, Grade(if applicable )

5. List all who live in the household: Names (Last Name, First Name, Birthdate, Grade(if applicable )

6. List all who live in the household: Names (Last Name, First Name, Birthdate, Grade(if applicable )

7. List all who live in the household: Names (Last Name, First Name, Birthdate, Grade(if applicable )

8. List all who live in the household: Names (Last Name, First Name, Birthdate, Grade(if applicable )

Annual Household Income *

0—$16,588

$16,589—$22,412

$22,413—$23,606

$23,607—$28,236

$28,237—$31,894

$31,895—$34,060

$34,061—$39,884

$39,885—$40,182

$40,183—$45,708

$45,709—$48,470

$48,471—$51,532

$51,533—$56,758

$56,759—$57,356

$57,357—$65,046

$65,047—$73,334

$73,335—$81,622

$81,623+

Certification - The head of household or adult designee who completed this form must complete this certification section. I certify (promise) that all information on this form is true and that all income is reported to the best of my knowledge. I understand that this form may impact the amount of State or Federal funding allocated to my local school district. I understand that the information I have provided may be verified. *

Yes

Please enter your address *

Please enter your phone number *

Please enter your email address

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