Child Nutrition Eligibility & Education Benefit Application – Pullman Public Schools

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. If your child(ren) are enrolled in a Community Eligibility Provision (CEP) or Provision 2 school, completing this application will not impact your eligibility to receive meals at no cost.

List all students living with you that are attending school. If the student is in foster care, experiencing homelessness, or receiving migrant education services, indicate this by placing an “x” in the correct box for how often it is received.

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.

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.

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.

We are required to ask for information about your child(ren)'s race and ethnicity. This information is important and helps make sure we are fully serving our community. Responding to this section is optional and does not affect your child(ren)'s eligibiliility for free & reduced-price meals.

Child Nutrition Eligibility: The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced-price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (Basic Food), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced-price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.

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:

1. U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or

2. (833) 256-1665 or (202) 690-7442; or

3. Email Program.Intake@usda.gov

This institution is an equal opportunity provider.

Pullman School District’s Non-Discrimination Statement

The Pullman School District Board of Directors and the Pullman School District shall provide equal educational opportunity and treatment for all students in all aspects of the academic and activities programs without regard to race, religion, creed, color, national origin, age, honorably-discharged veteran or military status, sex, sexual orientation (including gender expression or identity), marital status, the presence of any sensory, mental or physical disability, participation in the Boy Scouts of America or the use of a trained dog guide or service animal by a person with a disability. The district will provide equal access to the Boy Scouts of America and all other designated youth groups listed in Title 36 of the United States Code as a patriotic society. District programs will be free from sexual harassment. The following employees have been designated to handle questions and complaints of alleged discrimination: Civil Rights Coordinator and Title IX Coordinator, Assistant Superintendent, (509) 332-3144, compliancecoord@psd267.org, and Section 504/ADA Coordinator, Assistant Superintendent (509) 332-3144, compliancecoord@psd267.org. 240 SE Dexter Street, Pullman, WA 99163. Applicants with disabilities may request reasonable accommodations in the application process by contacting the Personnel Coordinator at (509) 332-3584. Title IX inquiries may also be directed toward the U.S. Department of Education, Office for Civil Rights (OCR): https://www2.ed.gov/about/offices/list/ocr/index.html. Information about the nondiscrimination and sex-based discrimination policies and grievance procedures, and how to report a concern or complaint: https://www.pullmanschools.org/families/hib-and-discrimination/discrimination_sexual_harassment.