Lunch Information Form

Required

Student Namerequired
First Name
Middle (optional)
Last Name
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.

 

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.
I certify (promise) that all information on this application is true and that all income is reported:required
Must contain a date in M/D/YYYY format