INCOME ELIGIBILITY FORM 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. Grade Number of Students Public School Attendance Area Kindergarten 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.