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