Eligibility for P-EBT benefits is only for the days your child missed school due to a COVID related reason. COVID-related absences for purpose of P-EBT eligibility are defined as: Any absence where the school directs students to stay home for a COVID-related reason. By completing this form, you attest that your child missed access to an in-school meal was COVID related. For additional questions, visit the IDHS website and the P-EBT FAQ, email dhs.fcs.pebt@illinois.gov, or call the P-EBT Call Center at 1-833-621-0737.
Your Information
Your Student's Information
,
,
For the Attendance Months listed below, please enter the number days the missed access to in-school lunch was COVID Related. **Note, IDHS can only issue benefits for days that you attest are COVID related AND the school has indicated is potentially eligible. The maximum number of days for each month is listed on your Notice of P-EBT eligibility, under the section of “Potentially Eligible Benefit Days”. IDHS cannot issue benefits for more than that number of days.
Non-Discrimination
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the
USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from
discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights
activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print,
audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals who
are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.
Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the
USDA
Program Discrimination Complaint Form, (AD-3027) found online at:
How to File a 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:
- mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
- fax: (202) 690-7442; or
- email: program.intake@usda.gov
Additional Illinois Nondiscrimination Information
You may also write the Illinois Department of Human Services (IDHS) at Illinois Department of Human Services, Bureau of Civil
Affairs, 401 South Clinton St., 6th Floor, Chicago, Illinois, 60607 or call the IDHS Helpline Number at 1-800-843-6154 or
866-324-5553 TTY/Nextalk or 711 TTY Relay. IDHS, HHS, and USDA are equal opportunity providers and employers. The State of
Illinois provides reasonable accommodations according to Section 504 of the Rehabilitation Act of 1973 and the Americans with
Disabilities Act of 1990.
Attestation and Signature Penalty Statement
I certify (promise) that all information on this application is true and that the dates specified in my application are days
that my child did not attend school in person for a school-approved COVID-related reason. I understand that this information
is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am
aware that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted under applicable
State and Federal laws.
