Prairienet NetNeighbors Application Form

(only to be completed if you wish to apply for a free account)

INCOME GUIDELINE INFORMATION

Eligibility for the program is based on the following guidelines

Circle the family size (including foster children) and then circle the income that most closely corresponds to your household. Income should be at or below that listed on the income chart. Income is 150% of Department of Health and Human Services poverty guidelines.


		      Family 
		      Size 	Income
                  ------------------------
			1	$14,700
			2	$19,800
			3	$24,900
			4	$30,000
			5	$35,100
			6	$40,200
			7	$45,300
			8	$50,400
Type of documentation provided (please provide copies, documentation will not be returned)

The following is a list of documentation that can be used to prove eligibility for a NetNeighbor Membership Grant. You need to show the household's full income in order to apply. You must provide proof that you are low income each year in order to receive or renew a NetNeighbors account.

__ A copy of last year's completed tax form
__ Employment paystubs which includes the name of the employer, employee and has year to date totals. All paystubs for all family members should be submitted together
__ Public aid printout of cash assistance
__ Social Security letter which states amount of benefit per month
__ Documentation of eligibility for Free School Lunch
__ A copy of all of last year's W-2 forms for the household
__ Other ________________________________________________________

I understand that the information provided will be used to establish eligibility for the NetNeighbor Membership Grant and is confidential. I affirm that the information provided is accurate to the best of my knowledge and reflects my entire household income.

Date _____________ Signature __________________________


Last Updated 7/20/06