Our Lady of Hope Catholic School - Our Lady of Hope Regional School | Blackwood NJ

Family Survey 2011/2012

Please complete and return the survey below via email. It is important that you return this form to us even if your income does not meet any of these criteria in order for the survey to be considered a valid measure.

Please attempt to answer the questions listed below. Skip any questions you don't know the answer to.

Pick one fron the drop down menu the number of people in your family on the chart below, including all children:

Family Size / Annual Income Monthly Income Weekly Income

Family Size	Annual Gross Income	Monthly	Weekly
One	$20,147	$1,679	388
Two	27,214	2,268	524
Three	34,281	2,857	660
Four	41,348	3,446	796
Five	48,415	4,035	932
Six	55,482	4,624	1,067
Seven	62,549	5,213	1,203
Eight	69,616	5,802	1,339

For each additional family member, add $7,067, $589, $136.

Family Size:

Is your family's income equal to or less than any of the amounts listed next to your Family Size?

Yes
No

Are your children eligible for the NSLP (National School Lunch Program) which provides free or reduced lunches, breakfasts, snacks or milk at their school(s)?

Yes
No

Is your family eligible to receive food stamps?

Yes
No

Is your family eligible for medical assistance under Medicaid?

Yes
No

Does your family receive Temporary Assistance for Needy Families (TANF)?

Yes
No

Does your family receive Supplementary Security Income (SSI)?

Yes
No

Does your family receive housing assistance (section 8)?

Yes
No

Does your family receive home energy assistance(LIHEAP)?Yes

Yes
No

Family Name:
Address:
City:
State:
Zip:
Email:
If you answered yes to any of the preceding questions, please list the names of all school children living in your home, including which school they attend. Name of Child School Grade

Type in Verification