Fillable 2021 Missouri School Children Pandemic EBT (Summer P-EBT) (Missouri)

Fill Online, Printable, Fillable, Blank 2021 Missouri School Children Pandemic EBT (Summer P-EBT) (Missouri) Form

Use Fill to complete blank online MISSOURI pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

2021 Missouri School Children Pandemic EBT (Summer P-EBT) (Missouri)

On average this form takes 15 minutes to complete

The 2021 Missouri School Children Pandemic EBT (Summer P-EBT) (Missouri) form is 2 pages long and contains:

  • 2 signatures
  • 10 check-boxes
  • 49 other fields

Country of origin: US
File type: PDF

BROWSE MISSOURI FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
2021 Missouri School Children
Pandemic EBT (Summer P-EBT) Application
Complete this application if your student received/receives free or reduced meals at school. You must complete the entire application for it to
be processed. Each eligible child in your household will receive their own EBT card.
NOTE: If your child was approved for P-EBT benefits for the 2020-2021 school year you do not need to complete this application as they
are considered eligible for Summer P-EBT.
STEP 1: Tell us about the adult who will be our contact for this application
Head of Household/Parent/Guardian/Foster Parent (Last name, First Name):
Social Security Number (optional):
Head of Household Date of Birth:
Telephone number:
Household address as reported to school: (If homeless, please write homeless)
City:
State:
Zip code:
Mailing address if different from above:
City:
State:
Zip code:
Step 2: Tell us about the school age children (pre-kindergarten – 12th grade) you are applying for. Please indicate the
name of the School District the student attends (i.e. Columbia) and provide the name of the school (i.e. Beulah Ralph
Elementary), address of the building (i.e. 5801 S Hwy KK) and city (i.e. Columbia) where the child is enrolled.
If you have more than five (5) school aged children in the household, list the children on another paper application
Child 1 (Last Name, First Name)
Date of Birth
SSN (optional)
School District
How was your child certified to
receive free or reduced meals?
by application other
School Building Name
City
Child 2 (Last Name, First Name)
Date of Birth
SSN (optional)
School District
How was your child certified to
receive free or reduced meals?
by application other
School Building Name
City
Child 3 (Last Name, First Name)
Date of Birth
SSN (optional)
School District
How was your child certified to
receive free or reduced meals?
by application other
School Building Name
City
Child 4 (Last Name, First Name)
Date of Birth
SSN (optional)
School District
How was your child certified to
receive free or reduced meals?
by application other
School Building Name
City
Child 5 (Last Name, First Name)
Date of Birth
SSN (optional)
School District
How was your child certified to
receive free or reduced meals?
by application other
School Building Name
City
SUMMER PEBT APPL (09/2021)
Page 1 of 2
Step 4: Read & Sign this application
USDA Nondiscrimination Statement: In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights
regulations and policies, the USDA, its Agencies, offices and employees, and institutions participating in or administering USDA programs
are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or
retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape,
American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of
hearing or have speech disabilities may contact USDA through Federal Relay Service at (800) 877-8339. Additionally, program information
may be available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or write a letter addressed to USDA and provide in the letter all
of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter
to USDA by mail at U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W.,
Washington, D.C. 20250-9410, by fax (833) 256-1665 or email at program.intake@usda.gov.
This institution is an equal opportunity provider.
Penalty Warning: I certify (promise) that all information on this application is true and correct and that all income is reported. I understand
that this information is given in connection with the receipt of Federal funds. I understand that State or local school officials may verify the
accuracy of information in this application. I am aware that if I purposely give false information, my children may be denied benefits, and I
may be prosecuted under applicable State and Federal criminal laws.
Do not give false information, or hide information, to get or continue to get P-EBT benefits.
Do not give, trade, or sell P-EBT benefits to anyone not authorized to use them.
Do not alter any authorization document to P-EBT benefits you are not entitled to receive.
Do not use P-EBT benefits to buy ineligible items, such as alcoholic drinks or tobacco.
Do not use someone else’s P-EBT benefits for your household.
I understand the questions on this application. I know it is against the law to obtain or attempt to obtain benefits for which I am/we are not
entitled. Any false claim, statement, or concealment of any material fact whatever, in whole in part, may subject me to criminal and/or civil
persecution. As a result of the temporary closure of school due to the COVID-19 Pandemic, the children listed on this application are not
receiving Free or Reduced lunches at their school. I certify, under penalty of perjury, that the information I have given is correct and
complete to the best of my knowledge. I also authorize the release of any information necessary to determine the correctness of my
certification. I understand that if I disagree with any action taken on my case, I have the right to request a fair hearing orally or in writing.
Your signature:
DATE
Signature of witness (needed if you cannot sign your name):
DATE
Step 6: Return Completed Application to the Department of Social Services Family Support Division
Return the completed and signed application. Do not return this application to the school. Options for returning the application:
• Scan or email the completed and signed application to: FSD.MOPEBT@dss.mo.gov
, OR
• Mail to: Family Support Division, 615 E. 13
th
St, Kansas City, MO 64106
Application must be returned no later than October 10, 2021 for an eligibility determination.
SUMMER PEBT APPL (09/2021)
Page 2 of 2
SIGN HERE:
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

2021 Missouri School Children Pandemic EBT (Summer P-EBT) (Missouri)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 1 October 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document