Total Monthly Income
Any Other Income
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
Reason for Denial:
Above Threshold ______
Please provide us with any additional information in support of your application. All information will be kept strictly confidential.