Byron Bergen Central School District
Community Eligibility Provision (CEP)/Provision 2 non-base year Household Income Eligibility Form

Byron Bergen Central 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 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 the school named above. Call 585-494-1220 ex1015 Mary Della Penna, Food Service Director, if you need help.

1. List all children in your household who attend school:
Student Name
	School
	Grade/Teacher
	Foster Child
	No Income
	
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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: ________________________________________________	CASE #__________________________________

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, check box. If you have listed a foster child above, you must report their personal income.
Name of household member
	Earnings from work before deductions Amount / How Often
	Child Support, Alimony

Amount / How Often
	Pensions, Retirement Payments
Amount / How Often
	Other Income, Social Security
Amount / How Often
	No Income
	
	$ ________ / ________
	$ ________ / ________
	$ ________ / ________
	$ ________ / ________
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	$ ________ / ________
	$ ________ / ________
	$ ________ / ________
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	$ ________ / ________
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	$ ________ / ________
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	$ ________ / ________
	$ ________ / ________
	$ ________ / ________
	$ ________ / ________
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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.

Signature:	Date:

Email Address:

Home Phone

Work Phone

Home Address

DO NOT WRITE BELOW THIS LINE – FOR SCHOOL USE ONLY
	
Annual Income Conversion (Only convert when multiple income frequencies are reported on application) Weekly X 52; Every Two Weeks (bi-weekly) X 26; Twice Per Month X 24; Monthly X 12
SNAP/TANF/Foster
Income	Total Household Income/How Often:	Household Size:

Free Eligibility	Reduced Eligibility	Denied Eligibility Signature of Reviewing Official

CEP/Provision 2 Non-Base Year Household Income Form INSTRUCTIONS

PART 1

PART 2

PARTS 3 & 4

ALL HOUSEHOLDS MUST COMPLETE STUDENT INFORMATION. DO NOT FILL OUT MORE THAN ONE FORM FOR YOUR HOUSEHOLD. (1) Print the names of the children, including foster children, for whom you are applying on one form.
(2) List their grade and school.
(3) Check the box to indicate a foster child living in your household, and check the box for each child with no income.

HOUSEHOLDS GETTING SNAP, TANF OR FDPIR SHOULD COMPLETE PART 2 AND SIGN PART 4.
(1) List a current SNAP (Supplemental Nutrition Assistance Program), TANF (Temporary Assistance for Needy Families) or FDPIR (Food Distribution Program on Indian Reservations) case number of anyone living in your household. Do not use the 16-digit number on your benefit card. The case number is provided on your benefit letter.
(2) An adult household member must sign the form in PART 4. SKIP PART 3 - Do not list names of household members or income if you list a SNAP, TANF or FDPIR number.

ALL OTHER HOUSEHOLDS MUST COMPLETE ALL OF PARTS 3 AND 4.
(1) Write the names of everyone in your household, whether or not they get income. Include yourself, the children you are completing the form for, all other children, your spouse, grandparents, and other related and unrelated people living in your household. Use another piece of paper if you need more space.
(2) Write the amount of current income each household member receives, before taxes or anything else is taken out, and indicate where it came from, such as earnings, welfare, pensions and other income. If the current income was more or less than usual, write that person’s usual income. Specify how often this income amount is received: weekly, every other week (bi-weekly), 2 x per month, monthly. Ifno income, check the box. Thevalue of any child care provided or arranged, or any amount received as payment for such child care or reimbursement for costs incurred for such care under the Child Care and Development Block Grant, TANF and At Risk Child Care Programs should not be considered as income for this program.

USE OF INFORMATION STATEMENT

Wemayshare youreligibility informationwitheducation,health,andnutritionprogramsto help themevaluate,fund,ordeterminebenefits fortheirprograms,auditorsforprogramreviews, andlawenforcementofficials to help them look into violations of program rules.

DISCRIMINATION COMPLAINTS
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,orreprisalorretaliation forpriorcivilrights activity.

Program informationmay bemadeavailableinlanguages otherthanEnglish.Persons withdisabilities whorequirealternativemeans ofcommunicationtoobtainprogram information(e.g.,Braille,largeprint,audiotape,AmericanSignLanguage),shouldcontact the responsible state orlocalagency thatadministers theprogram orUSDA’s TARGET Centerat(202)720-2600 (voiceand TTY)orcontactUSDAthrough theFederalRelay 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 forCivilRights (ASCR)aboutthenature and date ofan alleged civilrights violation.The completed AD-3027 form orlettermustbe submitted to USDAby:

1.	mail: U.S.DepartmentofAgriculture
Office ofthe AssistantSecretary forCivilRights 1400 Independence Avenue,SW Washington,D.C.20250-9410;or

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

3.	email: program.intake@usda.gov

This institution is an equalopportunity provider.