DEMOGRAPHIC FORM

DEMOGRAPHIC FORM

2022-2023 ENROLLED STUDENT/FAMILY DEMOGRAPHIC INFORMATION FORM ALL INFORMATION IS KEPT CONFIDENTIAL

Each participant in this program is required by Broadway School of Music & Arts and the City of Cleveland, Department of Community Development to provide their annual income level to establish eligibility for this federally-funded program, and to verify race/ethnicity for data collection purposes only.

From the income characteristic listed below, please circle the number of persons in your household and the annual income level that matches your household size. Check the appropriate box for race and for ethnicity, when applicable. Sign your name to verify the information you supplied to the Agency is true.

Income Characteristics

Number of Persons in Household Extremely Low Income (0 to 30% of MFI), $ Very Low Income (31% to 50% of MFI), $ Low Income (51% to 80% of MFI), $
(Circle One) (Circle One)
1 $16,550 or less $16,551-$27,550 $27,551-$44,050
2 $18,900 or less $18,901-$31,450 $31,451-$50,530
3 $21,960 or less $21,961-$35,400 $35,401-$56,650
4 $26,500 or less $26,501-$39,300 $39,301-$62,900
5 $31,040 or less $31,041-$42,450 $42,451-$67,950
6 $35,580 or less $35,581-$45,600 $45,601-$73,000
7 $40,120 or less $40,121-$48,750 $48,751-$78,000
8+ $44,660 or less $44,661-$51,900 $51,901-$83,050
RACIAL CHARACTERISTICS (Check One)
White Black-African American Black-African American & White
Asian Asian & White Native Hawaiian-Other Pacific Islander
American Indian-Alaskan Native American Indian-Alaskan Native & Black American Indian-Alaskan Native & White
Other Multi-Racial
ETHNICITY
Check only if Hispanic or Latino Origin
MM slash DD slash YYYY
TO BE COMPLETED BY AGENCY