Chromebook Assistance Application Form

Submit one application per child requesting assistance.    
Current income verification must be submitted with the application each year to be processed.
Student Name: 
School:Telephone:
Applications will not be processed if income verification is not attached.

Household Members

Total Monthly Income

Any Other Income

Annual Income

1.

   

2.

   

3.

   

4.

   

5.

   

6.

   

7.

   

8.

   
If there are other circumstances we should be aware of please include them with this form.
Complete this form, and enclose copies of all documents listed below that are applicable to your family, Mail to: School Central Administration, 360 Lynn Fells Parkway, Melrose, MA 02176
 
APPLICATIONS WILL NOT BE PROCESSED IF INCOME VERIFICATION IS NOT ATTACHED.
  • Current year’s 1040 Federal tax form

  • Proof of unemployment

  • if Self-employed include Schedule C

  • Last three (3) pay stubs

  • TANF documentation

  • Last DSS custody form

  • Proof of Child Support payments

  • Proof of disability/Social Security payments

 

I certify that all of the above information is true and correct and that all income is reported.  I understand that this information is for the sole purpose of determining eligibility for assistance, that it will be kept confidential, and that deliberate misrepresentation of financial status will disqualify me from consideration of such assistance.

Parent/Guardian Signature: ___________________________________________________________________________

 

Please do not write in this space

  

Eligibility Determination:

Approved               ______

 

Denied         ______

Reason for Denial:

Above Threshold  ______
 

 

Incomplete  ______

Note:

   
Hardship Description

Please provide us with any additional information in support of your application. All information will be kept strictly confidential.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Notice of Nondiscrimination
All educational and non-academic programs, activities, and employment opportunities at Melrose Public Schools are offered without regard to race, color, sex, religion, ancestry, national origin, sexual orientation, disability, and any other class or characteristic protected by law.