Education Benefits Form SY 2024-2025 P-CCS – For Community Eligibility Provision Schools

This form is used to determine eligibility for your student(s) and for state benefits for which your child(ren)’s school may qualify. If you ONLY have students that attend Community Eligibility Provision (CEP) schools complete this form. If you have students that attend CEP AND other P-CCS locations please complete the Education and Nutrition Benefits form online at https://frapps.horizonsolana.com/PLYC01

Part A: STUDENT INFORMATION

Complete for ALL active students Pre-K through 12th Grade

How many students would you like to register(Required)

Student's Last Name(Required)

Student's First Name(Required)

Grade Level(Required)

School(Required)

Identify

Please identify if the student is homeless, migrant, runaway, or foster.

Other School(Required)

Student's Last Name(Required)

Student's First Name(Required)

Grade Level(Required)

School(Required)

Identify

Please identify if the student is homeless, migrant, runaway, or foster. Leave blank if none.

Other School(Required)

Student's Last Name(Required)

Student's First Name(Required)

Grade Level(Required)

School(Required)

Identify

Please identify if the student is homeless, migrant, runaway, or foster. Leave blank if none.

Other School(Required)

Student's Last Name(Required)

Student's First Name(Required)

Grade Level(Required)

School(Required)

Identify

Please identify if the student is homeless, migrant, runaway, or foster. Leave blank if none.

Other School(Required)

Student's Last Name(Required)

Student's First Name(Required)

Grade Level(Required)

School(Required)

Identify

Please identify if the student is homeless, migrant, runaway, or foster. Leave blank if none.

Other School(Required)

Student's Last Name(Required)

Student's First Name(Required)

Grade Level(Required)

School(Required)

Identify

Please identify if the student is homeless, migrant, runaway, or foster. Leave blank if none.

Other School(Required)

Part B: BENEFITS RECEIVED (if applicable)

If any member of your household receives Food Assistance Program (FAP), Supplemental Nutrition Assistance Program (SNAP), Family Independence Program (FIP), or FDPIR, provide the name and case number for the person who receives benefits. Bridge Card Numbers and Medicaid Numbers are NOT ACCEPTABLE case numbers.

Did any member of your household receives benefits from the Food Assistance Program (FAP), Family Independence Program (FIP), or FDPIR?(Required)

Program Name(Required)

Case Number(Required)

Part C: HOUSEHOLD SIZE

Household size(Required)

Household size (# of people)(Required)

Part D: ANNUAL HOUSEHOLD INCOME

Select the appropriate range of combined annual income for all people in the household (Include all income before taxes)

Select income range(Required)

Total annual income:(Required)

Part E: CERTIFICATION

The head of household or adult designee who completed this form must complete this certification section

Printed Name(Required)

Date(Required)

Address(Required)

City(Required)

Zip(Required)

Email Address(Required)

Home Phone(Required)

Work Phone