Household Application for Sun Bucks

Household Application for Sun Bucks

1. List all students living with you that are attending school. If the student is a foster child, homeless, or migrant, indicate this by checking the appropriate box. Include any personal income received by the student and check the correct box for how often it is received. Please scroll on table for all fields.*

Rows	Student's Last Name	Student's First Name	MI	Foster	Homeless	Migrant	Date of Birth	School	Grade	Student Monthly Income	Weekly	Bi-Weekly	2x Monthly	Monthly
1
2
3
4
5

2. If any member of your household currently participates in TANF/SNAP/MEDICAID, please write your case number here:
Select Benefit Below. If other, please attach to case number
Case Number

3. List the names of all other household members, enter income (in whole dollars) and check how often it is received. Please scroll on table for all fields.*

Rows	Last Name	First Name	MI	Earnings from work (before deductions)	Weekly	Bi-Weekly	2x Monthly	Monthly	Public Assistance Child Support, Alimony	Weekly	Bi-Weekly	2x Monthly	Monthly	Other Income (Pensions, Retirement Social Security, etc.)	Weekly	Bi-Weekly	2x Monthly	Monthly
1
2
3
4
5

I certify (promise) that all information on this application is true, that all income is reported, and that no one included on this application is receiving Summer EBT in another state or from another agency. I understand that this information is given in connection with the receipt of federal funds and that some information included may be verified. I am aware that ifl purposely give false information, I may be liable to pay any monies received and may be prosecuted under applicable state and federal law.
Adult Household Member Signature*
Date*

MonthDayYear
Date
Adult Household Member's Printed Name*
Email Address
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City, State, Zip Code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
HOUSEHOLD APPLICATION FOR SUN BUCKS
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Income Eligibility Guidelines July 1, 2025 - June 30, 2026 (adjusted annually)

Income Eligibility Guidelines July 1, 2025 - June 30, 2026 (adjusted annually)

Household Size	Annual	Monthly	2x Monthly	Bi-Weekly	Weekly
1	$ 28,953	$ 2,413	$ 1,207	$ 1,114	$ 557
2	$ 39,128	$ 3,261	$ 1,631	$ 1,505	$ 753
3	$ 49,303	$ 4,109	$ 2,055	$ 1,897	$ 949
4	$ 59,478	$ 4,957	$ 2,479	$ 2,288	$ 1,144
5	$ 69,653	$ 5,805	$ 2,903	$ 2,679	$ 1,340
6	$ 79,828	$ 6,653	$ 3,327	$ 3,071	$ 1,536
7	$ 90,003	$ 7,501	$ 3,751	$ 3,462	$ 1,731
8	$ 100,178	$ 8,349	$ 4,175	$ 3,853	$ 1,927
Each additional	$ 10,175	$ 848	$ 424	$ 392	$ 196

If your household income is at or below Income Eligibility Guidelines, your child(ren) may qualify for SUN Bucks.
If you have moved or intend to move out of state, apply in the state your child will attend school before the next summer period.
If you need help completing this application, a non-household member may complete this form for you as your authorized representative.
Incomplete forms will delay processing.
We are required to ask about your children's race or ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children's eligibility for Summer EBT.
Hispanic or LatinoNot Hispanic or Latino
American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
The Richard B. Russell National School Lunch Act requires that we use information from this application to determine who qualifies for Summer EBT (SUN Bucks) benefits. We can only approve complete forms. We may share your eligibility information with education, health, and nutrition programs to help them deliver program benefits to your household. Inspectors and law enforcement may also use your information to make sure that program rules are met. Some children qualify for Summer EBT without an application. Please contact your State or ITO to get Summer EBT for a foster child, and children who are homeless, migrant, or runaway.
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the state or local agency that administers the program or contact USDA through the Telecommunications Relay Service at 711 (voice and TTY). Additionally, program information may be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027External link opens in new window or tab. (PDF), found online at How to File a Program Discrimination 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: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Mail Stop 9410, Washington, D.C. 20250-9410; (2) fax:202-690-7442; or (3) email: Program.Intake@usda.gov.
This institution is an equal opportunity provider.
HOUSEHOLD APPLICATION FOR SUN BUCKS
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