Academic Year:

School Name:

Student Name:

Parent/Guardian Name:

What documentation was used to verify household income? (Check all that apply)

1040 W-2 or final paystub for last yearPaystubs (minimum of 2 months, dated Oct-Dec of current or prior year)Employer statement on company letterheadGovernment benefit cardSocial Security benefitsDOE Choice approval (either a current year award letter or screenshot from the direct approval system)Other (if other, please use text field below to explain)

Does the family have any other income for the year that needs to be added to the W-2 income (business income, income reported on a form 1099, taxable IRA distributions, etc.)? If yes, please attach documentation.

Yes (documentation attached)No, the only income is documented with the W-2(s) provided

Paystubs should show income for pay period as well as a year to date summary. What is the estimated annual income for the job documented by the paystubs?

What is the reason that the tax return is not provided?

Has the family experienced a significant change in income?

YesNoN/A

Briefly explain the circumstances for any change in income from the previous tax return:

Is household size different from what is listed on tax return?

YesNoN/A

If household size above is different than the number on the tax return, please explain:

If household income is very low or zero, the family may not be an independent economic unit (for example, they may be living with friends or family who are providing support). If they are not an independent economic unit then the income and household size must be increased to incorporate all that are in the family economic unit. Is there other income which should be considered for this household?

YesNo

Please explain:

SEC INCOME ASSURANCE FORM