Arkansas Parent-Initiated P-EBT Application
District Name: Deer/Mt. Judea School District                                                                                   LEA#: 5106000

Pandemi-EBT (P-EBT) is a federal program. The Division of Elementary and Secondary Education (DESE), in collaboration with the Department of Human Services (DHS), received approval to operate this program in response to the COVID-19 related school closures. P-EBT provides food supports to help families with children who were receiving free and reduced-price school meals pay for food.

Eligibility for P-EBT:

1. The student must qualify for free or reduced priced meals

2. The student must have been absent due to COVID-19

**Benefits are only allowed on planned school calendar days. Benefits are not allowed on weekends or holidays.

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Select School Name *
Student First Name *
Student Middle Name
Student Last Name *
Student Date of Birth *
MM
/
DD
/
YYYY
Student Address *
Please provide address in the format of: address 1, address 2, city, state (AR), zip code
Parent Full Name *
Date student was absent or attended school virtually due to COVID-19 isolation/quarantine (MM/DD/YY) *
For multiple dates, separate by commas: 11/01/21, 11/02/21, 11/03/21
Certification
By submitting this application, I certify (promise) that all information on this application is true and that the dates specified in my application are days that my child did not attend school in person for a school-approved COVID-related reason. I understand that this information is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits and I may be prosecuted under applicable state and federal laws.
I understand that in order to process this application, DESE will share personally identifiable information (PII) about the student listed on this application with DHS, including but not limited to the information on this application. I consent to DESE sharing the above-listed student’s PII with DHS for the purpose of processing this application.
Parent/Guardian Email
Parent/Guardian Telephone/Mobile #
USDA Non Discrimination 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, disability, age, 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 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: https://www.usda.gov/oascr/how-to-file-a-program-discrimination-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:

(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: (202) 690-7442; or
(3) email: program.intake@usda.gov.

This institution is an equal opportunity provider.
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