Self-Declaration of Family Status

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Child's Name

First Last

Child's Date of Birth

Primary Parent/Guardian's Name

First Last

Primary Parent/Guardian's DOB

Please provide family status. Select "+" sign to add additional members.

Name of Family Member

Relationship to Parent/Guardian

Does this person receive Supplemental Security Income (SSI)? Yes / No.

Does this person have income of their own other than SSI?

By signing this form:

• I certify that the family members listed above are related to me by blood, marriage, or adoption and reside in my household. • I certify that I help to support these family members by using my income to help pay for some or all of their living expenses, such as housing, utilities, food, and/or transportation. • I understand that if the persons listed above are determined to be part of my ‘family’ (for the purposes of Head Start eligibility), I am required to provide documentation for some or all of the income these individuals receive. • I certify that the information I have provided is accurate and truthful to the best of my knowledge. I understand that intentionally providing false, inaccurate, or incomplete information may result in a loss of my family’s eligibility to participate in the program.

Primary Parent/Guardian Signature

Date