Educational Benefit Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Students in Household List
Other Household Members
Check if any of these applicable to any child
Homeless
Migrant
Runaway
Name(s), Gross Income, and How Often It Is Received
I, undersigned, agree with the following statements:
I am an adult household member
I certify (promise) that all information on this form is true and that all income is reported.
I understand that the school will get state and federal funds based on the information I give.
I understand that school officials may verify (check) the information.
I understand that if I purposely give false information, my child(ren) may lose benefits.
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: