School District Name: Buchanan MVA
Address 1: 18901 15 Mile Rd
Address 2: Suite 200
City, State, Zip: Clinton Township, MI, 48035
To determine eligibility for various additional state and federal program benefits that your child(ren) may qualify for, please complete, sign and return this application to Buchanan Schools.
These sections must be completed by the head of household or designee.
PART A. SIZE OF FAMILY - Enter the number of individuals living in your household, including all adults and children →
PART B. CURRENT BENEFITS - Complete below if applicable
PART C. STUDENT INFORMATION - Complete for each student Pre-K through 12th Grade*
*For the IDENTIFY field please use the following:
H if Homeless,
M if Migrant,
R if Runaway,
F if Foster,
N/A if Not Applicable
If you need additional lines, attach a second sheet to this survey or attach a copy of this survey clearly marked as Page 2.
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. Simply sign and date form.
Type of income
Check if no income
1. Gross Monthly Earnings: Wages, Salary, Comissions
2. Monthly Welfare Payments, Child Support, Alimony
3. Monthly Payments from Pensions, Retirement, Social Security
4. Monthly Dividends or Interest on Savings
5. Monthly Worker's Compensation, Unemployment, Strike Benefits
6. Other Monthly Income (SSI, VA, Disability, Farm, Other)
Total Monthly Household Income (Add lines 1-6)
PART E. SIGNATURE - If Income Section is completed, the adult signing the form must also list the last four (4) digits of his or her Social Security Number or check the "I do not have a Social Security Number" box below.