School year 22-23 Public School COVID Attestation

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 include: (1) Any absence where the school directs students to stay home for a COVID-related reason. This would include a school-ordered quarantine of a student, a group of students, a classroom, or a school; (2) Any other stay-at-home order mandated by the school, whatever its duration, if it is part of the school's or the State's protocol for managing COVID outbreaks, positive tests, and/or potential exposure; and (3) An absence initiated by the parent that is recognized and accepted by school officials as COVID-related. At the discretion of the school or the state, this could include a parent/guardian's decision to keep their child home after a positive test or possible exposure to COVID. It could also include, again at the discretion of the school or the State, a parent/guardian's decision to keep their child home after exposure at school in cases where the school does not direct the child to stay home.

By completing this form, you attest that your child missed access to an in-school meal that 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.

Guardian's Information

Guardian First Name:

Guardian Last Name:

Guardian Address:

Guardian City, State, ZIP:

Guardian County: Adams Alexander Bond Boone Brown Bureau Calhoun Carroll Cass Champaign Christian Clark Clay Clinton Coles Cook Crawford Cumberland DeKalb DeWitt Douglas DuPage Edgar Edwards Effingham Fayette Ford Franklin Fulton Gallatin Greene Grundy Hamilton Hancock Hardin Henderson Henry Iroquois Jackson Jasper Jefferson Jersey Jo Daviess Johnson Kane Kankakee Kendall Knox Lake LaSalle Lawrence Lee Livingston Logan Macon Macoupin Madison Marion Marshall Mason Massac McDonough McHenry McLean Menard Mercer Monroe Montgomery Morgan Moultrie Ogle Peoria Perry Piatt Pike Pope Pulaski Putnam Randolph Richland Rock Island Saline Sangamon Schuyler Scott Shelby St. Clair Stark Stephenson Tazewell Union Vermilion Wabash Warren Washington Wayne White Whiteside Will Williamson Winnebago Woodford Other

Guardian Phone:

Guardian Email:

Student's Information

Student First Name:

Student Last Name:

Student Address:

Student City, State, ZIP:

Student County: Adams Alexander Bond Boone Brown Bureau Calhoun Carroll Cass Champaign Christian Clark Clay Clinton Coles Cook Crawford Cumberland DeKalb DeWitt Douglas DuPage Edgar Edwards Effingham Fayette Ford Franklin Fulton Gallatin Greene Grundy Hamilton Hancock Hardin Henderson Henry Iroquois Jackson Jasper Jefferson Jersey Jo Daviess Johnson Kane Kankakee Kendall Knox Lake LaSalle Lawrence Lee Livingston Logan Macon Macoupin Madison Marion Marshall Mason Massac McDonough McHenry McLean Menard Mercer Monroe Montgomery Morgan Moultrie Ogle Peoria Perry Piatt Pike Pope Pulaski Putnam Randolph Richland Rock Island Saline Sangamon Schuyler Scott Shelby St. Clair Stark Stephenson Tazewell Union Vermilion Wabash Warren Washington Wayne White Whiteside Will Williamson Winnebago Woodford Other

Student Date of Birth:

Student Information System (SIS) ID that is printed on your notice above Potentially Eligible Benefit Days table. This will assist in processing your request. (optional):

For the Attendance Months listed below, please enter the number of days that 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, (including sexual orientation and gender identity), religious creed, 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:

1. mail: U.S. Department of Agriculture
   Office of the Assistant Secretary for Civil Rights
   1400 Independence Avenue, SW
   Washington, D.C. 20250-9410;
2. fax: (202) 690-7442; or
3. 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.

• I have read, understood and accept the penalty statement above.

Type your name below to sign this Attestation form: