Wyoming Pandemic Electronic Benefit Transfer (P-EBT) Application
Email address *
Name of Parent or Guardian (hereafter Applicant) *
Applicant's Date of Birth (DOB) *
MM
/
DD
/
YYYY
Applicant's Social Security Number(SSN) (example 555-55-5555)
Applicant's Telephone Number
Applicant's Mailing Address - Street *
Applicant's Mailing Address - City *
Applicant's Mailing Address - Zip Code *
Applicant's Physical Address (if different than mailing address above)(Steet, City, Zip Code)
School District or National School Lunch Program (NSLP)-Particpating Non-Public School Children Attend *
First and Last Name of Child (1) *
DOB of Child (1) *
MM
/
DD
/
YYYY
SSN of Child (1)
Current Education Level of Child (1)
First and Last Name of Child (2)
DOB of Child (2)
MM
/
DD
/
YYYY
SSN of Child (2)
Current Education Level of Child (2)
First and Last Name of Child (3)
DOB of Child (3)
MM
/
DD
/
YYYY
SSN of Child (3)
Current Education Level of Child (3)
First and Last Name of Child (4)
DOB of Child (4)
MM
/
DD
/
YYYY
SSN of Child (4)
Current Education Level of Child (4)
First and Last Name of Child (5)
DOB of Child (5)
MM
/
DD
/
YYYY
SSN of Child (5)
Current Education Level of Child (5)
First and Last Name of Child (6)
DOB of Child (6)
MM
/
DD
/
YYYY
SSN of Child (6)
Current Education Level of Child (6)
If any additional children in the household please list their first and last name, DOB, SSN, and Current education level here.
Name of Other Parent or Gaurdian in Household
DOB of Other Parent or Gaurdian in Household
MM
/
DD
/
YYYY
SSN of Other Parent or Gaurdian in Household
Is your household currently receiving SNAP benefits in Wyoming? *
If you have received SNAP benefits in Wyoming, do you still have your WY EBT card?
Next
Never submit passwords through Google Forms.
This form was created inside of State of Wyoming.