Issuu on Google+

For Office Use Only: Date Received

Mother’s Last Name

School District(s)

S I E D A

Operation Backpack is coordinated through the efforts of United Way of Mahaska County, the Salvation Army, Love in the Name of Christ, and SIEDA, with the support of numerous community organizations. The program provides backpacks and many school supplies (from district supply lists) to children of families at no more than 190% of the federal poverty level. It is not on a first-come, first-served basis: we help those first who are in need the most. We fill eligible applications until we have exhausted our funding. Applicants must be residents of Mahaska County. Families applying to the program must provide proof of income if they have not also applied for energy (LIHEAP) assistance from SIEDA within the past three years. For additional information about what documentation is acceptable, please see the back of this form. ALL APPLICATIONS MUST BE MAILED OR RETURNED IN PERSON DIRECTLY TO SIEDA IN OSKALOOSA NO LATER THAN JULY 13, 2012. APPLICATIONS MUST NOT BE RETURNED TO SCHOOL DISTRICTS OR OTHER AGENCIES. APPLICATIONS WILL NOT BE ACCEPTED AFTER THE DEADLINE. Please address your envelope in the following manner: Operation Backpack c/o SIEDA 114 North Market Street Oskaloosa, IA 52577 CLEARLY PRINT the following: Parent/Guardian; Mother’s Last Name:

Mother’s First Name:

Parent/Guardian; Father’s Last Name:

Father’s First Name:

Street Address: City, State & Zipcode: Phone Number(s): Alternate Contact & His/Her Phone Number:

1.

Student’s Last Name: Gender (circle):

Male

Student’s First Name: Female

Grade for ‘12-’13 School Year:

School Name:

List additional children on the back of this form. By signing this form I give my permission for the above entities to verify the accuracy of the information I have provided on this form as well as verify my family’s income. I understand that if I am requested to provide documentation of my family’s income and do not comply or if I misrepresent my income my application will be voided and I will not receive assistance through Operation Backpack this year. I allow any such information I provide to be released only among the above parties for the purpose of processing my application.

Parent/Guardian Signature (required to process application)


For additional children, CLEARLY PRINT the following:

2.

Student’s Last Name: Gender (circle):

3.

Grade for ‘12-’13 School Year:

Male

Male

Male

Male

Female

Grade for ‘12-’13 School Year:

Male

School Name:

Student’s First Name: Female

Grade for ‘12-’13 School Year:

School Name:

Student’s First Name: Female

Grade for ‘12-’13 School Year:

School Name:

Student’s First Name: Female

Grade for ‘12-’13 School Year:

Student’s Last Name: Gender (circle):

School Name:

Student’s First Name:

Student’s Last Name: Gender (circle):

8.

Female

Student’s Last Name: Gender (circle):

7.

Male

School Name:

Student’s First Name:

Student’s Last Name: Gender (circle):

6.

Grade for ‘12-’13 School Year:

Student’s Last Name: Gender (circle):

5.

Female

Student’s Last Name: Gender (circle):

4.

Male

Student’s First Name:

School Name:

Student’s First Name: Female

Grade for ‘12-’13 School Year:

School Name:

Acceptable forms of documentation determining total family income: • • • • •

Paycheck Stubs (from last 13 weeks) IRS Tax Returns for past two years Food Stamps Statements (NOT just your card) Title 19 Statements (NOT just your card) FIP Statements

• • • • •

Unemployment Statements Disability Statements Social Security Statements (SSI or SSDI) HUD Statement Completed and Accepted FAFSA

Please note that we only require you to provide one type of verification from the list above. If you possess another type of income documentation that you must use for this purpose, please call Robin at Love INC (641-676-3750) before submitting it to have it pre-approved.


Operation Backpack Application