Application – Summer EBT

Summer EBT Application

Fill out an application for each student you are applying for Summer EBT. To use this application the student must have attended a school participating in the National School Lunch Program in school year 2023-2024. Do not fill out an application if your student has been (as of July 1, 2023) or is currently on SNAP, OWF, Medicaid and the household income would qualify the student for free or reduced-price meals, the student is already approved for free or reduced price meals in the 2023-2024 school year, or the student is homeschooled or is a fully virtual student.

Student Information

The following student information is required to complete the application.

First Name (required)

Middle

Last Name (required)

Suffix

Date of Birth (required)

MM/DD/YYY format

SNAP Case Number

Ohio Works First (OWF) Case Number

District of Enrollment (required)

If the student's school is not listed, please know that schools that participate in the traditional NSLP will submit eligible students. Students attending schools that do not participate in the NSLP are not eligible for Summer EBT.

School in District (required)

Current Grade (required)

Student Sex (required)

Male

Female

Student Status (required)

Homeless

Migrant

Run-Away

Foster

None of these apply

Household Information

Please provide information for the student's household.

Is the student an emancipated youth?

An emancipated minor is a minor who has been judicially emancipated from their parents, or has reached the age of majority and is therefore free from the custody and control of their parents.

I am an emancipated youth

First Name of Parent/Guardian (required)

Last Name of Parent/Guardian (required)

Residential Address

Address (required)

City (required)

State (required)

Zip (required)

Mailing Address

Same as Residential Address

Address (required)

City (required)

State (required)

Zip (required)

Total number of people in household including children (required)

Monthly Income Information

For each household member, list each type of income received for the month. For earnings, be sure to list the gross income - not the take-home pay. Gross income is the amount earned before taxes and other deductions and can be found on pay stubs. For other income, list the amount each person received assistance from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veteran's benefits (VA benefits), and disability benefits. Under All Other Income, list Worker's Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household and any other income. Do not include income from SNAP, FDPIR, WIC, federal education benefits and foster payments received by the family from the placing agency. For ONLY the self-employed, report income after expenses under Earnings from Work. This is for your business, farm, or rental property. If you are in the Military Privatized Housing Initiative or receive combat pay, do not include these allowances as income.

View Income Eligibility Guidelines

Household Member #1

First Name (required)

Last Name (required)

Monthly earnings from work before deductions (required)

Monthly public assistance, child support, alimony (required)

Monthly pensions, retirement, all other income (required)

Total monthly income for this household member

Total monthly income for entire household

Confirm & Submit

You must agree to each term and condition stated below and provide your information so we can contact you if we have any questions.

I certify (promise) that all information on this application is true and correct and that all income is reported. understand that this information is given in connection with the receipt of Federal funds. (required)

I understand that state or local school officials may verify the accuracy of information in this application. (required)

If my child's homeschooled or virtual school status changes during the school year, and my child enrolls in an in-person school, I will notify the state immediately. (required)

I am aware that if I purposely give false information or fail to promptly notify the state of my child's enrollment in an in-person school, my child may be denied beneﬁts, and I may be prosecuted under applicable state and federal criminal laws. (required)

Non-Discrimination 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/ad-3027.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:

Mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410; or
Fax:
(833) 256-1665 or (202) 690-7442; or
Email:
Program.Intake@usda.gov

This institution is an equal opportunity provider.

Please provide your name and contact information in case we need to contact with any questions.

First Name (required)

Last Name (required)

Email (required)

Phone (required)

(000) 000-0000 format

Total People Living In Household

Annual	Monthly	Twice per Month	Every Two Weeks	Weekly
Enter the number of people living in your household to view income eligibility for SEBT.