sEBT Assistance - Request Form

Guardian Information

First Name

Last Name

Preferred Phone

Phone

Oldest Child Information

Oldest Child's Name

Oldest Child Date of Birth

Description

Preferred Language

Have you received a Summer EBT card in the mail?

YesNo

Summer EBT Card Number

Which card did you receive?

Select a topic:

Please tell us what you need help with.

By submitting this form, you indicate that you have received permission from the person listed to submit this request. This information will be stored but will not be shared.