2026-2027 CEP Income Survey MFP and Federal Funding Purposes Only Δ 1Household Members2Assistance Programs3Income4Sign & Submit Please read before you beginFully complete one application per household. If you have completed the full form for at least one child, please return a partial form for all other children with only the child’s name and a signature.MFP AND FEDERAL FUNDING PURPOSES ONLYStep 1: Household MembersList ALL Household Members who are infants, children, and students up to and including grade 12.Household = Anyone who is living with you and shares income and expenses, even if not related.How many children are you listing?(Required)123456 or moreChild 1Child 1(Required) First Middle Last Child 1 – Grade(Required)Infant / ToddlerPre-KK123456789101112Child 1 – Student?(Required) Yes No Child 1 – Check all that apply Foster Child Homeless Child 2Child 2(Required) First Middle Last Child 2 – GradeInfant / ToddlerPre-KK123456789101112Child 2 – Student? Yes No Child 2 – Check all that apply Foster Child Homeless Child 3Child 3(Required) First Middle Last Child 3 – GradeInfant / ToddlerPre-KK123456789101112Child 3 – Student? Yes No Child 3 – Check all that apply Foster Child Homeless Child 4Child 4(Required) First Middle Last Child 4 – GradeInfant / ToddlerPre-KK123456789101112Child 4 – Student? Yes No Child 4 – Check all that apply Foster Child Homeless Child 5Child 5(Required) First Middle Last Child 5 – GradeInfant / ToddlerPre-KK123456789101112Child 5 – Student? Yes No Child 5 – Check all that apply Foster Child Homeless Additional children (6 or more)First NameMILast NameGradeStudent? (Yes/No)Foster Child / Homeless Add RemoveAdd one row per additional child. Step 2: Assistance ProgramsDo any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?(Required) Yes No If NO > Go to Step 3.If YES > Write a case number here then go to Step 4 (Do not complete Step 3).Case Number(Required) Step 3: Report Income for ALL Household MembersSkip this step if you answered “Yes” to Step 2.A. If your yearly household gross income is above $71,558 with 5 or less household members, skip to Step 4 to sign document.B. Child IncomeSometimes children in the household earn or receive income. Please include the TOTAL yearly income for children in your household.C. Number of All Household Members (including yourself)(Required)D. Total Annual Income(Required)List the YEARLY gross income (before taxes) for household. Include earnings from work, public assistance, child support, alimony, pensions, retirement or other income.What income should I include?Sources of Income for ChildrenEarnings from work — a child has a regular full or part-time job where they earn a salary or wagesSocial Security, including disability payments and survivor’s benefitsIncome from a person outside the household — a friend or extended family member regularly gives a child spending moneyIncome from any other source — regular income from a private pension fund, annuity, or trustSources of Income for AdultsEarnings from workSalary, wages, cash bonusesNet income from self-employment (farm or business)U.S. Military: basic pay and cash bonuses (do NOT include combat pay, FSSA, or privatized housing allowances); allowances for off-base housing, food and clothingPublic assistance / alimony / child supportUnemployment benefits, worker’s compensation, Supplemental Security Income (SSI)Cash assistance from State or local governmentAlimony payments, child support paymentsVeteran’s benefits, strike benefitsPensions / retirement / all other incomeSocial Security, including railroad retirement and black lung benefitsPrivate pensions or disability benefitsRegular income from trusts or estates, annuitiesInvestment income, earned interest, rental incomeRegular cash payments from outside the household Step 4: Contact Information and Adult Signature“I certify (promise) that all information on this application is true and that all income is reported.Street Address (if available) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Printed name of adult signing the form(Required)Signature of adult(Required)Today's date(Required) Email address (optional) If you enter an email address we will send you a confirmation that your survey was received. We will not email any of the information you entered above.
