Exhibit 17-1 -- Student Status Verification
Head of Household Name: ______________________________________________________________
Check A, B, or C, as applicable (note that students include those attending public or private elementary schools, middle or junior high schools, senior high schools, colleges universities, technical, trade, or mechanical schools, but does not include those attending on-the-job training courses):
A. _____ Household contains at least one occupant who is not a student, has not been a student, and will not be a student for five or more months during the current and/or upcoming calendar year (months need not be consecutive). If this item is checked, no further information is needed.
B. _____ Household contains all students, but is qualified because the following occupant(s) _____________________________ is/are a part-time student(s). Documentation of part time student status is required for at least one member of the household.
C. _____ Household contains all full-time students for five or more months during the current and/or upcoming calendar year (months need not be consecutive). If this item is checked, questions 1-5, below must be completed:
|1.||Is at least one student receiving assistance under Title IV of the Social Security Act?
|2.||Was at least one student previously under the care and placement responsibility of the state agency responsible for administering foster care? (provide documentation of participation)||Yes||No|
|3.||Does at least one student participate in a program receiving assistance under the Job Training Partnership Act, Workforce Investment Act, or under other similar, federal, state or local laws? (attach documentation of participation)||Yes||No|
|4.||Is at least one student a single parent with child(ren) and this parent is not a dependent of another individual and the child(ren) is/are not dependent(s) of someone other than a parent?||Yes||No|
|5.||Are the students married and entitled to file a joint tax return?||Yes||No|
Households composed entirely of full-time student that are income eligible and satisfy one or more of the above conditions are considered eligible. If questions 1-5 are marked NO, or verification does not support the exception indicated, the household is considered an ineligible student household.
Verification completed by: _______________
Date completed: ______________________