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CEP Education Benefit Form

Required

CommunityEligibilityProvision(CEP)/Provision2non-baseyear EducationBenefitForm
 
Nyack Public Schools is participating in the Community Eligibility Provision (CEP) or Provision 2 in a non-base year. All children in the school will receive meals/milk at no charge regardless of household income or completion of this form.This form is to determine eligibility for additional State and federal program benefits that your child(ren) may qualify for. Read the instructions on the back, complete only one form for your household, sign your name and return it to our school. Please call or email Pamela Hickey at (845)353-7036 or phickey@nyackschools.org if you need help.
1.List all children in your household who attend school:
Additional Student Information
Additional Student Information
Additional Student Information
Additional Student Information
Additional Student Information
Additional Student Information
2. SNAP/TANF/FDPIR Benefits:
If anyone in your household receives either SNAP, TANF or FDPIR benefits, list their name and CASE # here. Skip to Part 5, and sign the application.
Name:required
First Name
Last Name
3. Household Gross Income:
List all people living in your household, how much and how often they are paid (weekly, every other week, twice per month, monthly). Do not leave income blank. If no income, checkbox. If you have listed a foster child above, you must report their personal income.
Name of household memberrequired
First Name
Last Name
Select if
Name of household memberrequired
First Name
Last Name
Select if
Name of household memberrequired
First Name
Last Name
Select if
Name of household memberrequired
First Name
Last Name
Select if
Name of household memberrequired
First Name
Last Name
Select if
Name of household memberrequired
First Name
Last Name
Select if
Name of household memberrequired
First Name
Last Name
Select if
Name of household memberrequired
First Name
Last Name
Select if
Name of household memberrequired
First Name
Last Name
Select if
4. Signature: An adult household member must sign this application.
 
I certify (promise) that all the information on this application is true and that all income is reported. I understand that the information is being given so the school may receive federal funds. The school officials may verify the information and if I purposely give false information, I may be prosecuted under applicable State and federal laws, and my children may lose meal benefits.
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