Self-Declaration of Family Status

Child's Name
First Last
Child's Date of Birth
Month
Day
Year
Primary Parent/Guardian's Name
First Last
Primary Parent/Guardian's DOB
Month
Day
Year
By Checking this box,
I certify that my income helps to support the following people:
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
Month
Day
Year

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: