Income Self Dec. Statement

Associated Students’ Children Center Income Self Declaration Form

Date: Parent/Guardian Name: Child(ren)’s Name: ________________________________________________________ Current income is $

per month

The Associated Student’s Early Childhood Education Center (ASECEC) is required by the California Department of Education (CDE) Child Development Division to determine a family’s eligibility to receive state preschool services based on family size and income. Any fraudulent, false, incomplete, deceitful, or misleading information provided to ASECEC regarding status of income or family size, that is used to determine initial eligibility, my be grounds for termination of state preschool services. ASECEC is required to recover costs from the parents or guardian for state preschool services if it is determined that the child/family was ineligible for such services at the time of initial enrollment. I understand that ASECEC has the right to verify information presented for the purposes of determining eligibility to receive state preschool services.

Parent/Guardian Signature

Date

Agency Representative

Date