Fillable PANDEMIC EBT APPLICATION FOR STUDENT SCHOOL YEAR 2021-2022

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PANDEMIC EBT APPLICATION FOR STUDENT SCHOOL YEAR 2021-2022

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SY 2021-2022 ADA Compliant 4/13/2022
PANDEMIC EBT APPLICATION FOR STUDENT
SCHOOL YEAR 2021-2022
INSTRUCTIONS FOR PARENT OR GUARDIAN
TO APPLY:
Complete ONE APPLICATION PER STUDENT. The application must be completed and submitted to
your child’s district or school no later than August 31
st
2022.
SUBMIT THE FORM TO:
Camille Canto
Nebo School District
350 South Main
Spanish Fork Utah 84660
Camille.canto@nebo.edu
801-354-7436
If you need assistance filling out the application, contact:
Camille Canto / Mary Quist
Nebo School District
350 South Main
Camille.canto@nebo.edu Mary.quist@nebo.edu
801-354-7436 or 801-354-7438
Monday – Thursday 7:00-4:00 Friday 8:00-12:00
Fax: 801-354-7495
TO BE CONSIDERED FOR P-EBT BENEFITS
Each student must meet the following qualifications before proceeding to fill out this application.
1) The household received notification from the school food service department the student was:
a. Directly certified for free or reduced-price school meals for school year 2021-2022; or
b. Approved for free or reduced-price meal eligibility through a free and reduced-price
meal application for school year 2021-2022; or
c. Enrolled in a participating CEP/Provision 2 school.
Important Note: Accessing meals at no charge this school year does not automatically make a
student eligible for P-EBT benefits.
2) The student is enrolled in a brick-and-mortar school participating in the National School Lunch
Program. (Students enrolled in online or virtual only schools are NOT eligible for P-EBT
benefits.)
The daily rate for school year 2021-2022 P-EBT benefits is $7.10 for each eligible day the student
qualifies for P-EBT.
Information provided by the parent or guardian will be verified by the district/school and reported to
the Utah State Board of Education Child Nutrition Programs. The information will be reviewed and
shared with the Utah Department of Workforce Services. If approved, P-EBT benefits will be issued and
mailed through the United States Postal Service (USPS) to the address on file with the district/school or
provided on this application. The phone number and email address information on the application will
be used to contact the parent or guardian if the P-EBT card is returned by USPS due to a non-deliverable
address.
SY 2021-2022 ADA Compliant 4/13/2022
PANDEMIC EBT APPLICATION FOR STUDENT
SCHOOL YEAR 2021-2022
1. Complete the form by writing clearly or typing in the required information below.
School Name
Student ID or Lunch Number
Student Name
(Last Name, Middle Name, First Name)
Student Date of Birth
(Month, Day, Year)
Parent or Guardian Name
(Last Name, First Name)
Parent or Guardian Phone Number
Parent or Guardian Email Address
Student Mailing Address
(PO Box or Street, Unit/Apartment #,
City, State, ZIP Code)
2. Write or type in the dates (for example March 1, 2022 would be written as 3/1/2022) your
student had a COVID-related absence from school between September 1, 2021, through
May 31, 2022. Do not write or type in dates the school had a scheduled holiday or no
school due to a scheduled break. Dates the school switched to at home learning, remote
learning, or virtual learning due to COVID will be reported by the district/school separately.
3. Attestation and Signature of Parent or Guardian
● Completing this form for Pandemic EBT benefits for school year 2021-2022 is
voluntary.
● I swear the information written or typed on the application is true. I understand
false information provided is considered fraud and/or perjury.
SY 2021-2022 ADA Compliant 4/13/2022
● I understand if approved for P-EBT benefits the card will be mailed to the address
provided on this form.
Printed Name of Parent or Guardian
Signature of Parent or Guardian Date
SNAP 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), 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 the Federal Relay Service at (800)
877-8339. Additionally, program information may be made 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: How to File a Complaint, and 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:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
Fax: (833) 256-1665 or (202) 690-7442
Email: program.intake@usda.gov.
This institution is an equal opportunity provider.
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SY 2021-2022 ADA Compliant 4/13/2022
For District/School Use Only
Information the district or school staff will need to determine P-EBT eligible benefits. Record or
date stamp the application when received by the district/school.
● List of P-EBT qualifying school(s)
● School year 2021-2022 free or reduced-price meal student eligibility records
● Student enrollment date/withdrawal date
● Student absence records
If “NO” is marked for any of the following statements, the student is not eligible to receive
P-EBT benefits through the PANDEMIC EBT APPLICATION FOR STUDENT.
☐ YES
☐ NO
Student determined eligible for free or reduced-price school meals in
School Year 2021-2022.
☐Free ☐Reduced-Price ☐CEP ☐Provision 2
Record the date the student was approved for free or reduced-price
school meals (MM, DD, YYYY)
☐ YES
☐ NO
Student was enrolled in a P-EBT eligible school during the absent dates.
Record Student Enrollment Date (MM, DD, YYYY)
* If student had multiple enrollment and withdrawal dates, please add
this information to "Comments.”
Student Withdrawal Date (MM, DD, YYYY)
☐ YES
☐ NO
District/school has confirmed the COVID-related absences on the
application.
☐ YES
☐ NO
District/school has confirmed the COVID-related absences are not on
the same dates the school had a soft closure due to COVID or a
scheduled holiday or break.
Signature of District/School Employee Date
Comments/ Notes:
After confirmation of P-EBT eligibility, record the information from the PANDEMIC EBT APPLICATION
FOR STUDENT in the template LEA Student Information PEBT SY2022_Parent Application spreadsheet.
Information needed to complete fields in the template are listed in the “Field Definitions” tab. Report
the number of days the student had a COVID-related absence by month between September 2021
through May 2022. Exclude dates the school had soft closures due to COVID. Maintain original
parent/guardian applications and school information used to confirm P-EBT eligibility for any future
audits.
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PANDEMIC EBT APPLICATION FOR STUDENT SCHOOL YEAR 2021-2022

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Completed 8 June 2022

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