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

Family Survey 2011-2012

Find your family size and annual gross income level listed beside it on the chart printed below:

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 $6,067.
*This may be a foster child, an emancipated youth or a special education child over age 18.

1. Is your annual gross income less than this amount?

Yes
No

2. Is your family eligible to receive food stamps?

Yes
No

Are you receiving assistance under the aid to Families with Dependent Children Program (public assistance)?

Yes
No

Are any of your children eligible to receive medical assistance under the Medicaid program?

Yes
No

We have not checked any of the above lines because we do not wish to share this information

Yes
No

Family Name:
Address:
City:
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Email:
Public school district in which you reside:

List names and grade level of your children in our school:

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