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2023-2024 Alternate LCFF Household Income Survey

Completing this form helps ensure that your child's school receives all of the state and federal funds for which it qualifies. Thank you!

1. Student ID Number (also called lunch ID):
This is the most accurate way to identify your student’s record in our student information system.

Student ID numbers are printed on report cards and visible when logged into your student’s portal account. Please click for instructions on where to locate the student ID number in English and Spanish.

For any students who do not have a student ID, please enter '000000.' *This question is required. This question requires a valid number format.

2. Student Name
In order to help us confirm we correctly identify your student, please enter your student’s full name as it appears on the student’s birth certificate/adoption papers.
*This question is required.

Student's First Name
Student's Last Name

3. Student's Date of Birth
In order to help us confirm we correctly identify your student, please enter your student’s date of birth as it appears on the student’s birth certificate/adoption papers.
*This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar (MM/DD/YYYY format)

4. Current School
At which school is your student currently enrolled?
*This question is required.

5. What is your household size?

“Household Size” includes yourself and all people living in your household, whether they are related to you or not who share income and expenses (for example, children, grandparents, other relatives, or friends would all count). If you live with other people who are economically independent (for example, who do not share income with your children, and who pay a pro-rated share of expenses), do not include them.
*This question is required.

Based on your household size of 2, select the appropriate range for total monthly household income:

“Total Monthly Household Income” includes gross earnings from work; Welfare, Child Support, Alimony; Pensions, Retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits, (VA benefits), and disability benefits; Military Housing Allowances and Combat Pay; All Other Income.
Please see this page for detailed instructions.
*This question is required.

Based on your household size of 3, select the appropriate range for total monthly household income:

“Total Monthly Household Income” includes gross earnings from work; Welfare, Child Support, Alimony; Pensions, Retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits, (VA benefits), and disability benefits; Military Housing Allowances and Combat Pay; All Other Income.
Please see this page for detailed instructions.
*This question is required.

Based on your household size of 4, select the appropriate range for total monthly household income:

“Total Monthly Household Income” includes gross earnings from work; Welfare, Child Support, Alimony; Pensions, Retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits, (VA benefits), and disability benefits; Military Housing Allowances and Combat Pay; All Other Income.
Please see this page for detailed instructions.
*This question is required.

Based on your household size of 5, select the appropriate range for total monthly household income:

“Total Monthly Household Income” includes gross earnings from work; Welfare, Child Support, Alimony; Pensions, Retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits, (VA benefits), and disability benefits; Military Housing Allowances and Combat Pay; All Other Income.
Please see this page for detailed instructions. *This question is required.

Based on your household size of 6, select the appropriate range for total monthly household income:

“Total Monthly Household Income” includes gross earnings from work; Welfare, Child Support, Alimony; Pensions, Retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits, (VA benefits), and disability benefits; Military Housing Allowances and Combat Pay; All Other Income.
Please see this page for detailed instructions. *This question is required.

Based on your household size of 7, select the appropriate range for total monthly household income:

“Total Monthly Household Income” includes gross earnings from work; Welfare, Child Support, Alimony; Pensions, Retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits, (VA benefits), and disability benefits; Military Housing Allowances and Combat Pay; All Other Income.
Please see this page for detailed instructions. *This question is required.

Based on your household size of 8, select the appropriate range for total monthly household income:

“Total Monthly Household Income” includes gross earnings from work; Welfare, Child Support, Alimony; Pensions, Retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits, (VA benefits), and disability benefits; Military Housing Allowances and Combat Pay; All Other Income.
Please see this page for detailed instructions. *This question is required.

Please enter your household size and total monthly income below: *This question is required.

	Household size
	Total Monthly Income (in dollars $)

6. Please enter the name of the adult household member completing this form:
This information is needed in case we need to contact you for clarification. *This question is required.

First Name

Last Name

Email Address This question requires a valid email address.

Phone Number

7. This form is being submitted by *This question is required.

I certify (promise) that the information provided on this form is true and that I included all income. I understand that the school may receive state and federal funds based on the information I provide and that the information could be subject to review. *This question is required.

Clear

Signature of

Form was submitted by a Pasadena USD staff member on behalf of the parent/guardian *This question is required.

Staff Name
Job Title

8. Do you have another student for whom you need to submit an additional survey form?
Select yes below and we will automatically redirect you to a new survey form after submission of this current form. *This question is required.