Thank you for responding to your school's request for income demographic information. Your participation helps your school learn how to best serve students and families, and secure grants and funding for programs.

This survey should only take a few minutes.

On the next page, you will be asked to identify all students in your household who are enrolled in your school district. Please use their district-assigned ID if possible.

You will also be asked to enter your total annual income and the total number of people (including your students) in your household.

First, please select your state and then school district or charter organization.

USDA Nondiscrimination Statement

In accordance with federal civil rights law and USDA civil rights regulations and policies, the USDA, its agencies, offices, employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the state or local agency that administers the program or contact USDA through the Telecommunications Relay Service at 711 (voice and TTY). Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

Mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Mail Stop 9410, Washington, D.C. 20250-9410;

Fax: (202) 690-7442; or

Email: program.intake@usda.gov

USDA is an equal opportunity provider, employer, and lender.

Required by The State of Washington

This application may qualify you for: meal benefits, Summer EBT benefits (if enrolled in a NSLP/SBP school), reduced fees for other programs and activities, and/or help secure funding for your school district. If your child(ren) are enrolled in a Community Eligibility Provision (CEP) or Provision 2 school, completing this application will not impact your eligibility to receive meals at no cost.

By submitting this form, you attest to the following: "I certify that all information on this application is true, that all income is reported, and that my household does not receive Summer EBT benefits through a different State or Indian Tribal Organization (if applicable)."

Please list your student(s) and their information to the best of your ability.

Please enter your contact information so your school can reach you if they have questions.

Please enter the total annual income for all members of your household.

THANK YOU!

Your school district or charter school has received the results of your survey.

You may close this tab or window.