2023-24 Household Information Survey

The information below will be used to determine eligibility for programs that use free/reduced status for benefits such as fee waivers and utility discounts. This is not an application for free/reduced meals.

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Email *
School Name *
Parent Name *
Street Address *
City *
State *
Zip *
Student Legal Name (As on Birth Certificate)-List all students enrolled with HCVS *
Student  ID-List all students enrolled with HCVS (These are the numbers in their email addresses) *
Student Date of Birth-List all students enrolled with HCVS *
Student Grade-List all students enrolled with HCVS *
Please check the box to the right of your Household Size to indicate your Annual Gross Income

Household Size is 2 check the box to the right to indicate whether your income is

Below $36,482
Above $36,482
NA
Income
Household Size is 3 check the box to the right to indicate whether your income is
Below $45,991
Above $45,991
NA
Income
Household Size is 4 check the box to the right to indicate whether your income is
Below $55,500
Above $55,500
NA
Income
Household Size is 5 check the box to the right to indicate whether your income is
Below $65,009
Above $65,009
NA
Income
Household Size is 6 check the box to the right to indicate whether your income is
Below $74,518
Above $74,518
NA
Income

Household Size is 7 check the box to the right to indicate whether your income is

Below $84,027
Above $84,027
NA
Income

Household Size is 8 check the box to the right to indicate whether your income is

Below $93,536
Above $93,536
NA
Income

Household Size is 9 check the box to the right to indicate whether your income is

Below $103,045
Above $103,045
NA
Income


Household Size is 10 check the box to the right to indicate whether your income is

Below $112,554
Above $112,554
NA
Income

Household Size is 11 check the box to the right to indicate whether your income is

Below $122,063
Above $122,063
NA
Income

Household Size is 12 check the box to the right to indicate whether your income is

Below $131,572
Above $131,572
NA
Income

Signature: An adult household member must sign the application.

I certify that all information on this application is true and that all income is reported. 

Please Type your full Name to serve as your signature

*
A copy of your responses will be emailed to the address you provided.
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