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 U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

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

fax:
(833) 256-1665 or (202) 690-7442; or

email:
Program.Intake@usda.gov

This institution is an equal opportunity provider.

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.