INCOME ELIGIBILITY FORM Private School Students Living in Poverty

SAMPLE FORM for Private School Officials to Submit to LEAs*
Private School Students Living in Poverty
Please use one form for each public school district. Duplicate as necessary.
Name of Non-Public School____________________________________________________
Public School District_________________________________________
Please provide below the grades and geographic information verifying residence in a participating public
school attendance area of those families that meet the poverty criteria of ________ [insert here the poverty
criteria used—e.g., U.S. Department of Agriculture for the free and reduced price lunch program]. Do not
provide the names of the families or students.
Number of Students
Public School Attendance Area
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
* This is not an official Department of Education document. It is provided only as an example.