Survey Form

INSTRUCTIONS FOR COMPLETING
THE HOUSEHOLD INFORMATION SURVEY


If any member of your household receives benefits from the Food Assistance Program (FAP), Family Independence Program (FIP), or FDPIR, please follow these instructions:

A household member is any child or adult living with you.

Part A: Enter the total number of individuals living in your household, including all children in the space provided.

Part B: List the case number for any household member (including adults) receiving FAP,
 FIP, or FDPIR benefits

Part C: List the First and Last name, grade, school that the child is attending, and any special circumstances (H if
 homeless, M if Migrant, R if Runaway or F if a Foster Child, or not applicable)

Part D: Skip this part


Part E: Enter your name, information, and submit form.

If your household does NOT receive benefits from FAP, FIP, or FDPIR, please follow these instructions:

Part A: List the total number of individuals living in your household, including all children.

Part B: Skip this part.


Part C: List the First and Last name, grade, school that the child is attending, and any special circumstances (H if homeless, M if Migrant, R if Runaway or F if a Foster Child, or not applicable)
.

Part D: Enter all gross income for each type of income that applies. If you have no income
 for any 1 or more of the categories, enter "0"

Part E: Enter your name, information, and submit form.

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