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Are you the parent of a child (ren) under age
18? Yes No |
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Number of minor children in your
custody/household? _____ |
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Are you a custodial or non-custodial
parent? _________________ |
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Number of people in your immediate family?
______ |
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Please check your annual household income: |
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____$ 8,589 or less ___$ 8,590 - $11,453 ___$11,454
- $14,316 |
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____$14,317 – $17,179 ___$17,180 - $20,043 ___$20,044
- $23,220 |
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____$23,221 - $26,239 ___$26,240 - $29,260 ___$29,261
- $32,281 |
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____$32,282 - $35,300 ___$35,301 - $38,321 ___$38,322
- $41,340 ____$41,341 - $47,379 ___$47,380 - $53,419
___$53,420 or more |
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*When finished
please mail completed copies to: |
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Kathy Palmer, FVWDB |
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996 South Green Bay
Road |
Neenah,
WI 54956
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MSW/KP/emp.survey/10/01/01 |
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