All schools in Ansonia participate in the Community Eligibility Provision program through the State of Connecticut, which provides free breakfast and lunch to all Ansonia students. However, you can help our school system to potentially receive additional funding by completing the household income form below and signing it. This information is for district use ONLY;this information is confidential and is not shared.

1. Select the total number of people in your household. Be sure to include ALL children and adults, related and unrelated, that live in a single dwelling and share income and expenses.

2. Select the box that represents the range of annual household income. This should include all of the following income sources: work, welfare, child support, alimony, pensions, retirement, Social Security, SSI, VA benefits, child income, or other income. The amount should be BEFORE any deductions for taxes, etc.

Total Number of people in householdrequired

Select range of combined annual income for all people in your household (including all income sources listed above, before taxes)required

If the household size is more than 12, list the household size and total income:

List all students in the household(Include First Name/Last Name/Grade/School):required

I certify (promise) that all information on this application is true and that all income is reported:*

Yes No

Electronic Signaturerequired

Date of Completing this Formrequired (mm/dd/yyyy)

Street Address, Apt. #required

Cityrequired

Staterequired

Phone Numberrequired

Email addressrequired

DISCLAIMER

THESE ITEMS WILL BE REQUIRED AT A LATER DATE VIA APPOINTMENT ONLY

Birth Certificate of student
ID or License of Parent/Guardian
2 Proofs of Residence (Mortgage or rental agreement and utility bill) from Parent/Guardian
Child's Health Assessment form

ELECTRONIC SIGNATURE AGREEMENT: BY TYPING YOUR NAME IN THE BOX BELOW AND CLICKING THE "SUBMIT" BUTTON, YOU ARE SIGNING THIS AGREEMENT ELECTRONICALLY. YOU AGREE YOUR ELECTRONIC SIGNATURE IS HE LEGAL EQUIVALENT OF YOU MANUAL SIGNATURE ON THIS AGREEMENT. WHEN PRESSING "SUBMIT" YOU CONSENT TO BE LEGALLY BOUND BY THIS AGREEMENT'S TERMS AND CONDITIONS.

Electronic Signaturerequired

***DISCLAIMER***

DISCLAIMER