Part 3. Total Household Gross income (before deductions). Record each income List all income on the same line as the person who receives it. Check the box for how often it is received. only once. 1. Name 2. income and how often it was received (list only household members with income) Earnings from All other income Welfare, child Social Security, SSI, VA, work before support, alimony retirement benefits (such as Unemployment) benefits deductions. Weeks Weeks Weeks Monthly Monthly Monthly Weeks Monthly 2 2 2 2 Weekly Monthly Weekly Monthly Weekly Monthly Weekly Monthly Every Twice Every Twice Every Twice Twice X X (Example) Jane $200 $150 $0 $0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Part 3. Total Household Gross income (before deductions). List all income on the same line as the person who receives it. Check the box for how often it is received. Record each income only once. 1. Name (list only household members with income) 2. income and how often it was received Earnings from work before deductions. Weekly Every 2 Weeks Twice Monthly Monthly Welfare, child support, alimony Weekly Every 2 Weeks Twice Monthly Monthly Social Security, SSI, VA, retirement benefits Weekly Every 2 Weeks Twice Monthly Monthly All other income (such as Unemployment) benefits Weekly 2 Weeks Twice Monthly Monthly (Example) Jane $200 X $150 X $0 $0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Application%20for%20Free%20and%20Reduced%20Meals%20SY%2014-15.docx