Form

This application may qualify you for: Meal benefits, Summer EBT benefits (if enrolled in a NSLP/SBP school), reduced fees for other programs and activities, and/or help secure funding for your school district. Auburn School District is participating in the Community Eligibility Provision (CEP) completing this application will not impact your eligibility to receive meals at no cost.

List all students living with you that are attending school

List the names of all other household members - Enter income (in whole dollars) and CHECK how often it is received. If a household member does not receive income, write 0. If you enter 0 or leave the income sections blank, you are promising there is no income to report

List the names of all other household members - Enter income (in whole dollars) and CHECK how often it is received. If a household member does not receive income, write 0. If you enter 0 or leave the income sections blank, you are promising there is no income to report

List the names of all other household members - Enter income (in whole dollars) and CHECK how often it is received. If a household member does not receive income, write 0. If you enter 0 or leave the income sections blank, you are promising there is no income to report

Contact Information & Signature – Complete, sign, and return this application to:I certify (promise) that all information on this application is true, that all income is reported, and that my household does not receive Summer EBT benefits through a different State or Indian Tribal Organization (if applicable). I understand that this information is given in connection with the receipt of federal or state benefits and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose these benefits, and I may be prosecuted under applicable State and Federal laws.