Education Benefits

Required

District: New Paradigm for Education

Schoolrequired

Please select your child(s) school.

PART A: STUDENT INFORMATION – Complete for each student Pre-K through 12th Grade

Student’s Last Namerequired

Enter student last name. (Must contain only letters and spaces)

Student’s First Namerequired

Enter student first name. (Must contain only letters and spaces)

Grade Levelrequired

Select Grade Level

Schoolrequired

Please select your child(s) school.

Identifyrequired

Please select one

Please enter additional student information, if applicable.

Student’s Last Name

Enter student last name. (Must contain only letters and spaces)

Student’s First Name

Enter student first name. (Must contain only letters and spaces)

Grade Level

Select Grade Level

School

Please select your child(s) school.

Identify

Please select one

Please enter additional student information, if applicable.

Student’s Last Name

Enter student last name. (Must contain only letters and spaces)

Student’s First Name

Enter student first name. (Must contain only letters and spaces)

Grade Level

Select Grade Level

School

Please select your child(s) school.

Identify

Please select one

Please enter additional student information, if applicable.

Student’s Last Name

Enter student last name. (Must contain only letters and spaces)

Student’s First Name

Enter student first name. (Must contain only letters and spaces)

Grade Level

Select Grade Level

School

Please select your child(s) school.

Identify

Please select one

PART B: BENEFITS RECEIVED - If any member of your household receives Food Assistance Program (FAP), Family
Independence Program (FIP), or FDPIR, provide the name and case number for the person who receives benefits.
Bridge Card Numbers and Medicaid Numbers are NOT ACCEPTABLE case numbers.

Name

Please enter your full legal name. (Must contain only letters and spaces)

Case Number

Please enter case number. (Must contain only numbers)

PART C: HOUSEHOLD SIZE - Enter the total number of individuals living in your household, including all adults and
children

Household Sizerequired

Please enter your household size. (Must contain only numbers)

PART D: TOTAL MONTHLY HOUSEHOLD INCOME – Report income for all members of household excluding Foster
Children. If you have reported a case number above, you do not need to fill in this section. Move on to PART E.

Type of Incomerequired

Select income type/source.

Incomerequired

Please enter income, if applicable.

Type of Income

Select income type/source.

Income

Please enter income, if applicable.

Type of Income

Select income type/source.

Income

Please enter income, if applicable.

PART E: CERTIFICATION - The head of household or adult designee who completed this form must complete this
certification section.

I certify (promise) that all information on this form is true and that all income is reported to the best of my
knowledge. I understand that this form may impact the amount of State or Federal funding allocated to my local
school district. I understand that the information I have provided may be verified.

ELECTRONIC SIGNATURE ACKNOWLEDGEMENT AND CONSENT FORM

I, agree and understand that by signing the Electronic Signature Acknowledgment, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

Signaturerequired

Type full legal name. (Must contain only letters and spaces)

Printed Name

Type full legal name.

Daterequired

Must contain a date in M/D/YYYY format

Addressrequired

Enter your legal mailing address.

Cityrequired

Enter your city.

Zip Coderequired

Enter your zip code.

Email Addressrequired

Enter your email address.

Home Phonerequired

Enter your home phone number. (Must contain only letters and numbers)

Work Phone

Must contain only letters and numbers