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The application collects names of all household members, identifies SNAP or TANF case numbers, and includes special household categories such as homeless, migrant, runaway, Head Start, and foster child status. 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All Household Members  \n\n| NAMES OF ALL HOUSEHOLD MEMBERS (for Student only) (for Student only)\u003Cbr>First, Middle Initial, Last |  |  | SNAP OR TANF CASE NUMBER ONLY Skip to Part |  |  |  |  |  |  |  |  | Check if |  |  | Check if |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  |  |  | 4 if you list a SNAP or TANF case number. At least one SNAP/ |  |  |  |  |  |  |  |  | NO |  |  | Foster |  |  |\n|  |  |  | TANF must be provided below. If you receive Medicaid and were |  |  |  |  |  |  |  |  | Income |  |  | Child* |  |  |\n|  |  |  | not directly certified for free meals, you MUST apply based on |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  | household size and income. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n\n* A foster child is the legal responsibility of a welfare agency or court.  \n2. Homeless, Migrant, Runaway, or Head Start  \nHomeless  \nMigrant  \nRunaway  \nHead Start  \n3. Total Household Gross Income (before deductions) You must tell us how much and how often.  \n\n| A.\u003Cbr>NAMES\u003Cbr>(LIST ALL HOUSEHOLD MEMBERS WITH INCOME) | GROSS INCOME AND HOW OFTEN IT WAS RECEIVED (Example: $100/month; $100 /twice a month; $100/every other week; $100/week) |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  | B. Earnings From Work (Before Deductions) |  | C. Welfare, Child Support, Alimony |  | D. Pensions, Retirement,\u003Cbr>Social Security |  | E. Worker’s Comp. , Unemployment, SSI, etc. (All other income) |  |\n|  | Amount | How often? | Amount | How often? | Amount | How often? | Amount | How often? |\n| i . | $ |  | $ |  | $ |  | $ |  |\n| ii . | $ |  | $ |  | $ |  | $ |  |\n| iii . | $ |  | $ |  | $ |  | $ |  |\n| iv. | $ |  | $ |  | $ |  | $ |  |\n| v. | $ |  | $ |  | $ |  | $ |  |\n\n4. Signature  \n\n| Date | Printed Name of Adult Household Member | Signature of Adult Household Member |\n| --- | --- | --- |\n| 5. Contact Information | Home Telephone Number (Include Area Code) | Home Address (Number, Street, City, State, Zip Code) |\n| Work Telephone Number (Include Area Code) |  |  |\n\nSCHOOL USE ONLY  \n\n| \u003Cbr>INITIAL DETERMINATION\u003Cbr>TOTAL\u003Cbr>INCOME $   Per: | Annual Income Conversion Weekly X 52 Every 2 Weeks X 26 Twice a Month X 24 Once a Month X 12 Convert income only if different\u003Cbr>frequencies of pay are reported. |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  |  Week  | Every 2\u003Cbr>Weeks | | Twice a\u003Cbr>Month |  Month  Year | NUMBER IN HOUSEHOLD: | CHANGE IN\u003Cbr>STATUS:   Date |  |\n\nCurrently receive benefits based on:  \n homeless  SNAP orTANF  \nmigrant runaway  \nfoster child  \nhousehold’s income  \nDate Withdrawn  \n Head Start  \n  Signature of Determining Official  Date:   \n\n| Privacy Act Statement: The Illinois State Board of Education is requesting schools to collect the information on this form to assist schools in reporting student’s eligibility for state and federal benefits programs. You do not have to give this information, but if you do not, we cannot determine your child’s eligibility for additional benefits u","cbCaiey6uIbkeA3u","https://ap.wps.com/l/cbCaiey6uIbkeA3u","pdf",189154,"English","# 1. All Household Members\n## SNAP OR TANF Case Number Only\n# 2. Homeless, Migrant, Runaway, or Head Start\n# 3. Total Household Gross Income (before deductions)\n# 4. Signature\n# 5. Contact Information\n# School Use Only\n## Initial Determination and Income Conversion\n## Currently receive benefits based on","[{\"question\":\"What information must be provided for all household members?\",\"answer\":\"Enter names of all household members and, if applicable, provide the SNAP or TANF case number. At least one SNAP/TANF must be provided when that option is used.\"},{\"question\":\"How should total household gross income be reported?\",\"answer\":\"Report each income type and the amount received along with how often it was received (e.g., monthly, weekly, every other week). Income details are collected before deductions and include earnings, welfare/child support/alimony, pensions/retirement/Social Security, and other income.\"},{\"question\":\"What sections are completed by the school versus the applicant?\",\"answer\":\"Applicants complete household member details, income information, signature, and contact information. The school completes the “SCHOOL USE ONLY” section, including initial determination and income conversion.\"}]","HOUSEHOLD AND INCOME FORM - Application for 69-72 Income Benefits | PDF",1791603625]