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Brentwood UFSD Household Income Eligibility Form

Brentwood Union Free School District is participating in the Community Eligibility Provision (CEP) for the 2023-2024 school 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 during the school year. Complete only one form for your household.

Call (631) 434-2316 (Brentwood Food Service) if you need help.

If you prefer, you can download and print form to complete and return to your child's school by click on the button below.

Haga clic aquí para ver el formulario en español

Click here to download and print English form Download

Click here to download and print Spanish form Download

Part 1

List all children in your household who attend a school in Brentwood UFSD:

Enter the names of the children, including foster children, for whom you are applying on one form.
List their grade and school, etc.
Enter YES or NO to indicate a foster or Homeless/Migrant/Runaway child living in your household.

ALL HOUSEHOLDS MUST COMPLETE STUDENT INFORMATION. DO NOT FILL OUT MORE THAN ONE FORM FOR YOUR HOUSEHOLD.

Student Name	Date of Birth	School	Grade	Student ID #	Foster Child (Yes/No)	Homeless, Migrant, Runaway (Yes/NO)

Part 2

SNAP/TANF/FDPIR Benefits: If anyone in your household receives either SNAP, TANF, or FDPIR benefits, list their name and case # below.

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.
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.

HOUSEHOLDS GETTING SNAP, TANF OR FDPIR SHOULD COMPLETE PART 2 AND SKIP PART 3.

Name	Case #

Part 3

Household Gross Income: List all people living in your household, how much and how often they are paid. If you have listed a foster child above, you must report their personal income.

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.
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 from work before deductions, 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. If no income, please enter 0. The value 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.

ALL HOUSEHOLDS WHO DO NOT RECEIVE SNAP, TANF OR FDPIR MUST COMPLETE ALL OF PARTS 3.
How Often: weekly=W, every other week (bi-weekly)=BW, 2 x per month=TM, monthly=M. (Example: $1000 per month = 1000/M). If no income, please enter 0.

Name	Earning from work: Amount/How often	Child Support, Alimony: Amount/How often	Pensions, Retirement Payments: Amount/How often	Other Income, Social Security: Amount/How often

Part 4

Signature: An adult household member must sign this form.

Your First Name *

Your Last Name *

I certify (promise) that all the information on this form 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.

Type your name and sign below

Clear Show me how

Email Address *

Home Phone (Number) *

Work Phone (Number)

Home Address

PRIVACY STATEMENT (FERPA)

The Family Educational Rights and Privacy Act (FERPA) affords parents/ guardians and students over 18 years of age (referred to as “eligible students” in this notice) certain rights with respect to the student’s education records. They are:

1) The right to inspect and review the student’s education records within 45 days of the day the Brentwood School District receives a request for access. Parents/guardians or eligible students shall submit a written request to the school principal

that identifies the records they wish to inspect. The principal will make arrangements for access and notify the parent or eligible student of the time and place where the records may be inspected.

2) The right to request the amendment of student’s education records that the parent/guardian or eligible student believes are inaccurate or misleading. Parents/guardians or eligible students may ask the Brentwood School District to amend a record

that they believe is inaccurate or misleading. They should write to the school principal, clearly identifying the part of the record that they want to change, and specify why they believe it is inaccurate or misleading. If the Brentwood School District decides not to amend the record as requested by the parent/guardian or eligible student, it will notify the parent/ guardian or eligible student of the decision and advise them of their right to a hearing regarding the request for amendment. Additional information regarding the hearing procedures will be provided to the parent/guardian or the eligible student when notified of the right to a hearing.

3) The right to consent to disclosures of personally identifiable information contained in the student’s education records, except to the extent that FERPA authorizes disclosure without consent. One exception that permits disclosure without consent is disclosure to school officials with legitimate educational interests. A school official is a person employed by the Brentwood School District as an administrator, supervisor, instructor, or support staff member (including health or medical staff and security staff); a person serving on the Board of Education; a person or company with whom the Brentwood School District has contracted to perform a certain task (such as an attorney, auditor, medical consultant, or therapist), or a parent/guardian or student serving on an official committee, such as a disciplinary or grievance committee, or assisting another school official in performing his/her tasks.

A school official has a legitimate educational interest if the official needs to review an education record in order to fulfill his/her professional responsibilities. Upon request, the Brentwood School District discloses education records without consent to officials of another school district in which a student seeks or intends to enroll. Additionally, the revised Elementary and Secondary Education Act requires high schools to release student directory information (name, address, phone numbers) to military recruiters and “institutes of higher learning,” which includes colleges, trade schools and technical schools. However, under FERPA, parents/guardians have the right to prohibit the release of directory information without prior parental consent. If parents/guardians or students over the age of 18 wish to exercise this right, a written request must be sent within one (1) month from the first day of school to the, Assistant Superintendent for Secondary Education, at the Anthony F. Felicio Administration Building, 52 Third Avenue, Brentwood, NY 11717.

4) The right to file a complaint with the United State Department of Education concerning alleged failures by the Brentwood School District to comply with the requirements of FERPA. Further information about FERPA regulations is available in each school building in the District. FERPA is administered through the Family Policy Compliance Office, United States Department of Education, 400 Maryland Avenue, SW, Washington, DC 20202-4605.

Approvals

A number of approval stages need to be completed before this submission can be accepted.

Printed

Appropriate approvers from the Printed group will be automatically allocated for this approval stage.