PPESD Free & Reduced Lunch Verification Survey

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In California, schools receive additional money to run special programs, such as counseling services and academic supports, based on the income levels of the families we serve. WE NEED YOUR HELP! By answering a few confidential questions below, you can help our school district ensure that we receive the funding we're entitled to. If you have any questions about this survey, please contact your school office, and we can help. Thanks, in advance, for taking the time to complete this short survey. We greatly appreciate it!

The information submitted on this form is a confidential educational record and is therefore protected by all relevant federal and state privacy laws that pertain to educational records including, without limitation, the Family Educational Rights and Privacy Act of 1974 (FERPA), as amended (20 U.S.C. § 1232g; 34 CFR Part 99); Title 2, Division 4, Part 27, Chapter 6.5 of the California Education Code, beginning at Section 49060 et seq.; the California Information Practices Act (California Civil Code Section 1798 et seq.) and Article 1, Section 1 of the California Constitution.

Email *

Household Last Name *

Household Phone Number *

Names of any children attending Pollock Pines ESD *

Total number of children AND adults living in the household *

Option 6

Option 7

Option 8

Based on your household size and income, which category listed below, if any, does your household fall into? If your household size is greater than 8, please skip to the next question. *

Category 1

Category 2

Neither Category 1 or 2

If household size is greater than 8, please list the total number of adults and children in the household and your gross annual household income. If household size is less than 8, please skip this question.

Name of the adult household member completing this form. *

By clicking the box below, 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 and that the information could be subject to review. *

I certify (promise) that the information provided on this form is ture.

Required

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