Mana Academy P-EBT Application for Student

Mana Academy P-EBT Application for Student 2022-2023

INSTRUCTIONS FOR PARENTS/GUARDIANS: Complete ONE APPLICATION PER STUDENT. The application must be completed and submitted to us no later than Friday, July 15, 2022. If you need assistance filling out the application, contact: Raegan Nielsen at rnielsen@themanaacademy.org or call 801-972-6262 Tuesday-Thursday, 10-3:00 pm.

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:

Directly certified for free or reduced-price school meals for school year 2021-2022; or
Approved for free or reduced-price meal eligibility through a free and reduced-price meal application for school year 2021-2022; or
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.

Name of Student*

First NameMiddle NameLast Name

School ID or Lunch Number *

This is the four digit number found on Aspire. If you don't know your student's school ID number, contact our front desk.

Date of Birth*

Month/Day/Year

Parent or Guardian Name*

First NameLast Name

Parent or Guardian Phone Number*

Please enter a valid phone number.

Parent or Guardian Email Address*

example@example.com

Student Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Did your student miss any days from school due to COVID19? If so, enter the dates (for example March 1, 2022 would be written as 3/1/2022) 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 non-school day due to a scheduled break. *

Attestation and Signature of Parent or Guardian

Completing this form for Pandemic EBT benefits for school year 2022-2023 is
voluntary.
I swear the information written or typed on the 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.

Printed Name of Parent or Guardian*

Type your name here if you are a parent or guardian

Signature*

Date Signed*

Date

SNAP Nondiscrimination 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, religious creed, disability, age, political beliefs, 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), 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: How to File a 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 Mail:

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

This institution is an equal opportunity provider. ADA Compliant 4/13/2022

Complete the form by writing clearly or typing in the required information below.