Dear Parent/Guardian:

Schools receive certain federal and state funding (Learning Assistance Program, teacher incentives, etc.) based on the number of children from households that are at or below the federal poverty level.

This Family Income Survey provides your child's school a way to collect household income information.

This information makes sure your child's school receives the full amount of federal and state funding and makes sure your child receives services they are entitled to when free/reduced price applications ARE NOT collected.

* is a Required field

Step 1

• List all children living with you that are attending school.

BSD Student ID Student First Name* Student Last Name* Date of Birth* School* Grade (K-12)* Action
Are Any of the Listed Students:

Step 2

• List the names of all other members of the Household (Do NOT include students listed in Step 1).

HOUSEHOLD is defined as all persons, including parents, children, grandparents, and all people related or unrelated who live in your home and share living expenses. If you’re applying for a household with a foster child, you may include the foster child in the total household size.

First and Last Name* Action
Do any household members participate in:

Step 3

• Figure out your total household gross income before taxes.

• Look at the income chart below.

• Find your household size.

• If your total household gross income is equal to or less than the amount listed for your household size, check that box.

• Check None of these Apply if your household gross income for your household size is more than the corresponding income level.

HOUSEHOLD INCOME is any taxable income each household member received before taxes. This includes wages, social security, pension, unemployment, welfare, child support, alimony, and any other cash income. If including a foster child as part of the household, you must also include the foster child's personal income. Do not count foster payments as income.

Use This As A Guide On How Often Payment is Received
Make a Selection * Household Size Annual Income Monthly Twice Per Month Every Two Weeks Weekly
1 $26,973 $2,248 $1,124 $1,038 $519
2 $36,482 $3,041 $1,521 $1,404 $702
3 $45,991 $3,883 $1,917 $1,769 $885
4 $55,500 $4,625 $2,313 $2,135 $1,068
5 $65,009 $5,418 $2,709 $2,501 $1,251
6 $74,518 $6,210 $3,105 $2,867 $1,434
7 $84,027 $7,003 $3,502 $3,232 $1,616
8 $93,536 $7,795 $3,898 $3,598 $1,799
9 $103,045 $8,588 $4,295 $3,964 $1,982
10 $112,554 $9,381 $4,692 $4,060 $2,165
11 $122,063 $10,174 $5,089 $4,426 $2,348
12 $131,572 $10,967 $5,486 $4,792 $2,531
For each additional person, add: $9,509 $793 $397 $366 $183
None of these apply

Step 4

• Check the box for the program(s) that you consent to share your information

Family Engagement Specialist: Connects families with information about support services and resources in the community such as food, backpacks, school supplies, clothing, etc.

Fee Waiver Program: offers waived fees for IB, AP and World Language test; extracurricular activites such as ASB dues, event registrations, field trips, performances, social event/dances, sporting events, transportation fees, athletic fees, required uniforms; discounted summer school tuition.

Once your survey is processed for qualification, allow 3-5 business days to be activated in the Fee Waiver Program. Once activated, fee-waiver eligible items will be automatically reduced or waived at purchase. Fee waivers are not applied retroactively, and fees paid prior to becoming active in the Fee Waiver Program are not refundable.

By Acknowledging in Step 5, I allow the information contained in this survey to be shared with the programs I have checked.

Step 5

• Acknowledge your consent and type your name.

I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get state and federal funds based on the information I give. I understand that school officials may verify (check) this information. I understand if I purposely give false information that I may be prosecuted.

Please type your name and press Submit *

Bellevue School District does not discriminate in any programs or activities on the basis of sex, race, creed, religion, color, national origin, age, veteran or military status, sexual orientation, gender expression or identity, disability, or the use of a trained dog guide or service animal and provides equal access to the Boy Scouts of America and other designated youth groups. The following employees have been designated to handle questions and complaints of alleged discrimination:

  • Civil Rights, Racial Discrimination, and Gender Expression or Identity Discrimination: Civil Rights/Nondiscrimination Compliance Coordinator Nancy Pham, (425) 456-4040 or phamn@bsd405.org
  • Sex-based Discrimination, including Sexual Harassment: Title IX Coordinator: Jeff Lowell, (425) 456-4010 or lowellj@bsd405.org
  • Disability Discrimination: Section 504/ADA Coordinator: Heather Edlund, (425) 456-4156 or edlundh@bsd405.org

Mailing address for all three: 12111 NE 1st Street, Bellevue, WA 98005.