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Pandemic-EBT Application for School Year 2021-2022

To Apply for P-EBT for the 2021-2022 School Year:

Complete one (1) application per student atteding Grand County School District. The application must be completed and submitted to Grand County School District no later than August 31, 2022.

If you need assistance completing this application or would prefer a paper application please contact:

Alysha Packard, SNS

Director of Child Nutrition Programs

Grand County School District

[email protected]

(435) 259-2757

PEBT flowchart

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.

Required fields marked with an asterisk *

Student Information

Student First Name*

Answer Required

Student Middle Name*

Answer Required

Student Last Name*

Answer Required

Student School ID Number

Answer Required

Student Date of Birth*

Answer Required

Student Mailing Address

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Parent or Guardian Contact Information

Parent or Guardian First Name*

Answer Required

Parent or Guardian Last Name*

Answer Required

Parent or Guardian Email *

Answer Required

Parent or Guardian Phone Number*

Number Required

Select the date(s) your student had a COVID-related absence from school between September 1, 2021 through May 31, 2022. *

Do not include dates the school had a scheduled holiday or scheduled break.

Answer Required

Select the date(s) your student had a COVID-related absence from school between September 1, 2021 through May 31, 2022.

Do not include dates the school had a scheduled holiday or scheduled break.

Answer Required

Select the date(s) your student had a COVID-related absence from school between September 1, 2021 through May 31, 2022.

Do not include dates the school had a scheduled holiday or scheduled break.

Answer Required

List any additional dates your student had a COVID-related absence from school between September 1, 2021 through May 31, 2022 here.

Answer Required

Attestation of Parent or Guardian*

Please review and check the following statements:

Answer Required

Completing this form for Pandemic EBT benefits for school year 2021-2022 is voluntary.

I swear the information included on this application is true. I understand false information provided is considered fraud and/or perjury.

I understand if approved for P-EBT benefits the card will be mailed to the address provided on this form.

Signature of Parent or Guardian

ELECTRONIC SIGNATURE AND DISCLAIMER: Type your name below as your signature. By typing your name below, you are signing this document electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this agreement.

Parent or Guardian Signature*

Type your first and last name to sign electronically.

Answer Required

USDA Nondiscrimination Statement

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

(1) Mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;

(2) Fax: (833) 256-1665 or (202) 690-7442; or

(3) Email: [email protected].

This institution is an equal opportunity provider.

Confirmation Email

Email Required