S-EBT Alternative Income Application - HHS.ND.GOV

Instructions:

Please complete one form for the entire family, listing all school-age children and other members of the household.

If the household has recently moved, please apply for benefits in the State where your child will complete or has completed the school year 2023-2024.

A household is defined as a group of related or unrelated individuals who usually live together and share income and expenses.

Households with annual gross income at or below that listed on the Income Eligibility Guidelines below may be eligible for Summer EBT benefits.

Household Size	Maximum Annual Income
1	$26,973
2	$36,482
3	$45,991
4	$55,500
5	$65,009
6	$74,518
7	$84,027
8	$93,536
For each additional family member add	$9,509

The benefit is $120 per eligible school-aged child. Benefits are issued via an electronic benefit transmission card (EBT card). Each eligible child will receive an EBT card loaded with Summer EBT benefits.

Only one application can be submitted for each child. If more than one application is received for a child, benefits will be sent to the household listed as the primary parent/guardian with the child's school. Be sure to read and sign at the bottom of this application.

Households must submit an application for Summer EBT benefits by August 30, 2024 to receive benefits for the summer.

Head of Household (Parent/Guardian of Children)

First Name

*

Middle Initial

*

Last Name

*

Email Address

**

Phone #

*

Ethnicity

Primary Language spoken at home

Race

Current Household Mailing Address

Address Line 1

*

Address Line 2

*

City

*

State

ZIP Code

*