Dear Principal

Dear Principal,

As this 2015-16 school year begins, we are once again required to verify the numbers of students from low-income households. This accounting is used for State and Federal programs as well as official Archdiocesan records.

Please sendthe Student Low Income Form located on pages 2-4 of this document to your families.For your convenience, we have entered a due date of September 15, 2015. You may change this date to better serve your families’ needs if you wish. Please collect completed forms and keep them on file in the school office. You will need the for verification purposes and to complete the Nonpublic Data System (NPDS) in the winter.

Please sendthe Low Income School Summary Form located on page 5 to the Catholic Schools Office via email no later than October 30, 2015. Thank you for your assistance and cooperation. Be assured that this information is kept confidential, as only the number of students and their public school districts is reported.

Sincerely,

Jim Rigg, Ph.D.

Superintendent of Schools

(Reproduce on School Letterhead)

August or September, 2015

Dear Parents and Guardians:

All of our school families are asked to complete the enclosed student low income form. This information is very important to ensure our continued participation in various Federal and State programs. These programs provide a variety of materials and services for our children, teachers, and school. Programs affected include Title I, Free and Reduced lunch, and E-Rate.

This form must be completed by each family.

Your name will not be given out to anyone. The information will be kept confidential.

Through your participation, the children at our school may be able to get more funding and services

Parents/Guardians, please return the form to school by September 15, 2015.

Thank you for your assistance and cooperation with filling out this form. Please feel free to contact me if you have any questions.

Sincerely,

Principal

STUDENT LOW INCOME FORM (Page 1)

TO BE COMPLETED BY PARENTS/GUARDIAN
EffectiveJuly 1,2015 throughJune30, 2016

EXAMPLE

Mr. and Mrs. Smith are married and have 3 children. They earn $3,500 per month. Since they have 5 people in their household and make more than the monthly free column but less than the reduced column, they should circle the box below that indicates $4,380 in the Reduced column (shown below).

HOUSEHOLDSIZE / FREE / REDUCED
Numberof
Members / Annual / Monthly / TwicePer
Month / EveryTwo
Weeks / Weekly / Annual / Monthly / TwicePer
Month / EveryTwo
Weeks / Weekly
1 / $15,301 / $1,276 / $638 / $589 / $295 / $21,775 / $1,815 / $908 / $838 / $419
2 / 20,709 / 1,726 / 863 / 797 / 399 / 29,471 / 2,456 / 1,228 / 1,134 / 567
3 / 26,117 / 2,177 / 1,089 / 1,005 / 503 / 37,167 / 3,098 / 1,549 / 1,430 / 715
4 / 31,525 / 2,628 / 1,314 / 1,213 / 607 / 44,863 / 3,739 / 1,870 / 1,726 / 863
5 / 36,933 / 3,078 / 1,539 / 1,421 / 711 / 52,559 / 4,380 / 2,190 / 2,022 / 1,011
6 / 42,341 / 3,529 / 1,765 / 1,629 / 815 / 60,255 / 5,022 / 2,511 / 2,318 / 1,159
7 / 47,749 / 3,980 / 1,990 / 1,837 / 919 / 67,951 / 5,663 / 2,832 / 2,614 / 1,307
8 / 53,157 / 4,430 / 2,215 / 2,045 / 1,023 / 75,647 / 6,304 / 3,152 / 2,910 / 1,455
Each Additional MemberAdd / +5,408 / +451 / +226 / +208 / +104 / +7,696 / +642 / +321 / +296 / +148

Directions: Please circle the number in the chart below that corresponds to your household size and pay frequency.

INCOME CONVERSION:

WeeklyIncome / x 52 / = Annual income
Every2WeeksIncome(Everyotherweek,Bi-weekly) / x 26 / = Annual income
TwiceaMonthIncome(Bi-monthly) / x 24 / = Annual income

Return to the School Office by September 15

STUDENT LOW INCOME FORM (Page 2) – TO BE COMPLETED BY PARENTS/GUARDIAN

Dear Parent/Guardian:

In accordance with the guidelines on the previous page, does your household qualify for Free Lunch, Reduced Lunch, or neither? (Check one)

Free Lunch

Reduced Lunch

Does not qualify for Free or Reduced Lunch______

Name(s) of student(s) attending this school:______

______

(Please add the names of additional siblings who attend this school on the back, if necessary)

Address:

City, State, Zip

By signing below I verify the information I have given on this form:

Printed Name of Person filling out this form______

Signature:Date:

Return to the School Office by September 15

LOW INCOME SCHOOL SUMMARY FORM

NAME OF CATHOLIC SCHOOL:

Public School District where Catholic School is located:

You May Not Include Pre-School or Pre-K in Either of These Counts

A:IN-STATE ADM (Include only K-12 students from Ohio)

TOTAL ADM(Includes all K-12 students)______

B:Total number of students qualifying for free lunch

C: Total number of students qualifying for reduced lunch______

D: Total number of students who qualify for neither______

Principal’s Signature.

PLEASE RETURN BY EMAIL TO:

Pam Jaspers -

CATHOLIC SCHOOLS OFFICE

In order for our schools to receive the State and Federal monies, it is imperative that we indicate true low-income counts. Please send home a letter and form to EVERY parent to obtain that accurate number.