Educational Benefit Form

ALL Clark Co. Public School students will receive free breakfast and lunch for the 2021-2022 school year. However, to maximize the district’s ablity to receive additional state and federal program benefits, we need ALL households to complete and submit this form, regardless of economic status!

Only one form per household is needed.

PART 2. BENEFITS -- SNAP/KTAP ONLY

If any member of your household receives SNAP or KTAP, provide the name and case number for the person who receives benefits and skip to part 5. If no one receives these benefits, go to Part 3.

PART 3. HOMELESS, MIGRANT, RUNAWAY STATUS

If any child you are applying for is homeless, migrant, or a runaway, check the appropriate box and call the district FRAM Coordinator.

PART 4. TOTAL HOUSEHOLD GROSS INCOME (BEFORE deductions)

List all income on the same line as the person who receives it. Use the drop-downs to indicate where and how often it is received. Record each income only once. If you provided a case number in Part 2, you do not need to provide income information. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.

Legend for 2nd column above:

"1" = Earnings from work before deductions

"2" = Public assistance, child support, alimony

"3" = Pensions, retirement, Social Security, SSI, VA benefits, All Other Income

PART 5. SIGNATURE

(ADULT HOUSEHOLD MEMBER MUST SIGN)

I certify (promise) that all information on this form is true and that all income is reported. I understand that the school will get state and federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my child(ren) may lose benefits.

HOUSEHOLD CHECKLIST

• Have you included all your children as household members in Part 1?
• For each household member receiving income in Part 4, are both dropdowns selected?
• Have you signed the form below?

Non Discrimination Statement: In accordance with Federal Law and U.S. Department of Education policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, gender identity, age, or disability. To file a complaint of discrimination, write U.S. Department of Education, Office for Civil Rights, The Wanamaker Building, 100 Penn Square East, Suite 515, Philadelphia, PA 19107-3323 or call (215) 656-8541 (Voice). Individuals who are hearing impaired or have speech disabilities may contact U.S. DOE through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). The U.S. Department of Education is an equal opportunity provider and employer.

Privacy Notice
The Kentucky Department of Education is requiring schools to collect the information on this form. You do not have to give this information, but if you do not, we cannot determine your child’s eligibility for additional benefits under state and federal programs. We will hold the information you provide us as private and confidential to the extent required by law. However, we will share your socioeconomic status with various state and federal programs to help them evaluate, fund, or determine benefits for their programs, with auditors for program reviews, and with law enforcement officials to help them look into violations of program rules. Regardless, all students enrolled in a Community Eligibility Provision school will receive meals at no charge.

DO NOT FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY.

Annual Income Conversion: Weekly x 52; Every 2 Weeks x 26; Twice A Month x 24; Monthly x 12